cdc compendium of effective fall interventions: what works for

A CDC Compendium of Effective Fall Interventions:What Works for Community-Dwelling Older Adults

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A CDC Compendium of Effective Fall Interventions:

What Works for Community-Dwelling Older Adults

3rd Edition

by Judy A. Stevens, Ph.D. and Elizabeth Burns, MPH

Division of Unintentional Injury Prevention National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Atlanta, Georgia

2015

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A CDC COMPENDIUM OF EFFECTIVE FALL INTERVENTIONS: WHAT WORKS FOR COMMUNITY-DWELLING OLDER ADULTS

This document is a publication of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention:

Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director

National Center for Injury Prevention and Control Debra Houry, MD, MPH, Director

Division of Unintentional Injury Prevention Grant Baldwin, PhD, MPH, Director

Home, Recreation, and Transportation Branch Ann Dellinger, PhD, MPH, Branch Chief

Home and Recreation Injury Prevention Team Robin Lee, PhD, MPH, Team Lead

Authors Judy A. Stevens, PhD and Elizabeth Burns, MPH

ACKNOWLEDGEMENTSTo Dr. Ellen Sogolow, in appreciation of her foresight and leadership in developing the Compendium, a document that has been instrumental in promoting the dissemination and implementation of effective evidence-based falls interventions for older adults.

We acknowledge and appreciate the support of Dr. Christine Branche in the initial phase of this project; the important contributions of Dr. Patricia D. Nolan, Mr. David Ramsey, Ms. Lisa Jeannotte, Ms. Bonny Bloodgood, and Ms. Sondra Dietz in collecting and organizing these data; and the thoughtful review and constructive suggestions of Dr. David Sleet, Dr. Daphne Moffett, Dr. Michael Ballesteros, Dr. Rita Noonan, Dr. Grant Baldwin, Dr. Ann Dellinger, and Dr. Robin Lee.

Suggested Citation: Stevens JA, Burns ER. A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults. 3rd ed. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2015.

Disclaimer: Reference herein to any specific commercial products, programs, or services by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the United States Government. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government, and shall not be used for advertising or product endorsement purposes.

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CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Single Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Exercise 5

Stay Safe, Stay Active Barnett, et al. (2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The Otago Exercise Program Campbell, et al. and Robertson, et al. (1997, 1999, 2001, 2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

LiFE (Lifestyle approach to reducing Falls through Exercise) Clemson, et al. (2012). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Erlangen Fitness Intervention Freiberger, et al. (2007) . . . . . . . . . . . . . . . . . . . . . 16

Senior Fitness and Prevention (SEFIP) Kemmler, et al. (2010) . . . . . . . . . . . . . . . . . 18

Adapted Physical Activity Program Kovacs, et al. (2013) . . . . . . . . . . . . . . . . . . . . 20

Tai Chi: Moving for Better Balance Li, et al. (2005) . . . . . . . . . . . . . . . . . . . . . . . 22

Australian Group Exercise Program Lord, et al. (2003) . . . . . . . . . . . . . . . . . . . . . 24

Yaktrax® Walker McKiernan (2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Veterans Affairs Group Exercise Program Rubenstein, et al. (2000) . . . . . . . . . . . . . 28

Falls Management Exercise (FaME) Intervention Skelton, et al. (2005) . . . . . . . . . . . 30

Music-Based Multitask Exercise Program Trombetti, et al. . . . . . . . . . . . . . . . . . . 34

Central Sydney Tai Chi Trial Voukelatos, et al. (2007) . . . . . . . . . . . . . . . . . . . . . . 36

Simplified Tai Chi Wolf, et al. (1996) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Multi-target Stepping Program Yamada, et al. (2013). . . . . . . . . . . . . . . . . . . . . . 40

Table 1. Summary Table of studies and Study Population . . . . . . . . . . . . . . . . . . . 44

Table 2. Study Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Table 3. Intervention Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Home Modification 55

The VIP Trial Campbell, et al. (2005) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Home Visits by an Occupational Therapist Cumming, et al. (1999). . . . . . . . . . . . . . 58

Falls-HIT (Home Intervention Team) Program Nikolaus, et al. (2003) . . . . . . . . . . . . 60

Home Assessment and Modification Pighills, et al. (2011) . . . . . . . . . . . . . . . . . . . 62

Table 1. Summary Table of studies and Study Population . . . . . . . . . . . . . . . . . . . 65


Table 3. Intervention Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

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Clinical 69

Three-Year Study of Vitamin D (Cholecalciferol) Plus Calcium Bischoff-Ferrari, et al. (2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Psychotropic Medication Withdrawal Campbell, et al. (1999) . . . . . . . . . . . . . . . . 72

Active Vitamin D (Calcitriol) as a Falls Intervention Gallagher, et al. (2007) . . . . . . . . 74

VISIBLE (Visual Intervention Strategy Incorporating Bifocal and Long-distance Eyewear) Study Haran, et al. (2010) . . . . . . . . . . . . . . . . . . . . 76

Vitamin D to Prevent Falls After Hip Fracture Harwood, et al. (2004) . . . . . . . . . . . . 79

Cataract Surgery Harwood, et al. (2006) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Pacemaker Surgery Kenny, et al. (2001) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Study of 1000 IU Vitamin D Daily for One Year Pfeifer, et al. (2009) . . . . . . . . . . . . . 85

Quality Use of Medicines Program Pit, et al. (2007) . . . . . . . . . . . . . . . . . . . . . . . 87

Podiatry & Exercise Intervention Spink, et al. (2011) . . . . . . . . . . . . . . . . . . . . . . 90

Table 1. Summary Table of studies and Study Population Characteristics . . . . . . . . . 94


Table 3 Intervention Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Multifaceted Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Stepping On Clemson, et al. (2004) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

PROFET (Prevention of Falls in the Elderly Trial) Close, et al. (1999) . . . . . . . . . . . . 107

Accident & Emergency Fallers Davison, et al. (2005) . . . . . . . . . . . . . . . . . . . . . 109

The NoFalls Intervention Day, et al. (2002) . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

The SAFE Health Behavior and Exercise Intervention Hornbrook, et al. (1994) . . . . . . . . . . . . . . . . . . . . . . . . 115

Falls Team Prevention Program Logan, et al. (2010). . . . . . . . . . . . . . . . . . . . . . 118

KAAOS (Falls and Osteoporosis Clinic) Palvanen, et al. (2014) . . . . . . . . . . . . . . . . 120

Multifactorial Fall Prevention Program Salminen, et al. (2009) . . . . . . . . . . . . . . . 124

Nijmegen Falls Prevention Program (NFPP) for adults with Osteoporosis Smulders, et al. (2010) . . . . . . . . . . . . . . . . . . . . . 127

The Winchester Falls Project Spice, et al. (2009) . . . . . . . . . . . . . . . . . . . . . . . 130

Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) Tinetti, et al. (1994) . . . . . . . . . . . . . . . . . . . . . . . . . 133

A Multifactorial Program Wagner, et al. (1994) . . . . . . . . . . . . . . . . . . . . . . . . 136

Table 1. Summary Table of studies and Study Population Characteristics . . . . . . . . 139

Table 2. Study Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Table 3. Intervention Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

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TAblE OF CONTENTS

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Appendix A: Intervention Study selection process 149

Appendix B: Bibliography of Compendium Studies and Supplemental Articles 153

Appendix C: Intervention Study selection process 160

Appendix C-1 Barnett Materials Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Appendix C-2 Kovacs Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

Appendix C-3 Voukelatos Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Appendix C-4 Wolf Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Appendix C-5 Haran Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Appendix C-6 Pit Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Appendix C-7 Spink Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Appendix C-8 Close Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Appendix C-9 Spice Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

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Introduction

IntroductionOlder adults value their independence and a fall can significantly reduce their ability to remain self-sufficient. More than one-third of people aged 65 and older fall each year, and those who fall once are two to three times more likely to fall again.1 Among older adults, falls are the leading cause of both fatal and nonfatal injuries2 and are responsible for significant disability, hospitalization, loss of independence, and reduced quality of life.3 Most fractures among older adults are caused by falls.4 Falls also have a huge economic impact. Direct medical costs for fall injuries total $34 billion annually.5 However, we know that falls are not an inevitable result of aging. In recent years, systematic reviews of fall intervention studies have established that prevention interventions can reduce falls.6

PurposeThis report is intended to showcase specific interventions for which there is published evidence of the intervention’s ability to reduce falls among community-dwelling older adults. The compilation of this information can help public health practitioners, senior service providers, clinicians, and others who want to address falls in their community.

More than one-third of people aged 65 and

older fall each year, and those who fall once are

two to three times more likely to fall again.

1 Tromp AM, Pluijm SMF, Smit JH, et al. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001;54(8):837–844

2 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013

3 Wolinsky F D, Fitzgerald J F, Stump T E. The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. Am J Public Health 1997.

4 Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Academic Emergency Medicine 2000;7(2):134–40.

5 Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006a;12:290–5.

6 Gillespie, LD, Robertson, MC, Gillespie, WH, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3. Introduction

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ProcessFor this 3rd edition of the Compendium, CDC gathered information about fall prevention studies that met the following criteria:

• Published in the peer-reviewed literature

• Included community-dwelling adults aged 60 and older

• Used a randomized controlled study design

• Was specifically designed to be a fall prevention intervention

• Measured falls or the proportion of fallers as an outcome

• Demonstrated statistically significant positive results in reducing older adult falls

• Took place in a community or clinical setting

This selection methodology differed from previous versions in that the selected age criteria was changed from 65 and older to 60 and older. Interventions implemented in clinical settings also were included. A literature review was conducted in 2014 and identified 12 interventions published between January 1, 2009 and September 30, 2014. We also identified seven interventions published before 2009 that met the expanded criteria.

See Appendix A for details about the selection process and methods used for the earlier editions.

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INTrODuCTION

ContentThe Compendium classifies interventions into two main groups: single interventions and multifaceted interventions.

Multifaceted interventions address multiple fall risk factors. Some multifaceted interventions include an assessment of each participant’s fall risk factors and provide an individually tailored intervention plan.

Single interventions address a specific fall risk factor (e.g. treating gait and balance issues with physical therapy). Single interventions are further categorized as exercise, home modification, and clinical interventions.

Twenty nine single interventions (15 exercise interventions, 4 home modification interventions, and 10 clinical interventions) and 12 multifaceted interventions are included in the 3rd edition of the Compendium. Information about each intervention was obtained from the published study and by direct communication with the study’s principal investigator. Each is presented using a standardized format that includes a short summary of the intervention, study results, and a section describing additional details about the intervention. These include:

• Purpose

• Program setting

• Content

• Number of sessions

• Duration

• Type of provider

• Provider’s training

• Key elements

• Available materials

• Contact information for the principal investigator.

At the end of each section are tables comparing the participating populations, study characteristics, and intervention characteristics.

The Compendium also contains appendices. These include figures illustrating the intervention selection process; a bibliography of the research interventions; and supplemental materials, such as assessment instruments.

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Single Interventions

ToC3Exercise

SINGlE INTErVENTIONS

Exercise Stay Safe, Stay Active Barnett, et al (2003) 6

The Otago Exercise Program Campbell, et al and Robertson, et al (1997, 1999, 2001, 2005) 8

LiFE (Lifestyle approach to reducing Falls through Exercise) Clemson, et al (2012) 12

Erlangen Fitness Intervention Freiberger, et al (2007) 16

Senior Fitness and Prevention (SEFIP) Kemmler, et al (2010) 18

Adapted Physical Activity Program Kovacs, et al (2013) 20

Tai Chi: Moving for Better Balance Li, et al (2005) 22

Australian Group Exercise Program Lord, et al (2003) 24

Yaktrax® Walker McKiernan (2005) 26

Veterans Affairs Group Exercise Program Rubenstein, et al (2000) 28

Falls Management Exercise (FaME) Intervention Skelton, et al (2005) 30

Music-Based Multitask Exercise Program Trombetti, et al 34

Central Sydney Tai Chi Trial Voukelatos, et al (2007) 36

Simplified Tai Chi Wolf, et al (1996) 38

Multi-target Stepping Program Yamada, et al (2013) 40

Table 1 Summary Table of Studies and Study Population 44

Table 2 Study Methodology 45

Table 3 Intervention Characteristics 52

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Stay Safe, Stay Active Barnett, et al. (2003) This study used weekly structured group sessions of moderate-intensity exercise, held in community settings, with additional exercises performed at home. Participants were 40 percent less likely to fall and one-third less likely to suffer a fall-related injury compared with those who did not receive the intervention.

Population: Participants were individuals at risk of falling because of lower limb weakness, poor balance, and/or slow reaction time. All were aged 67 or older and lived in the community. About two-thirds of participants were female.

Geographic Locale: Southwest Sydney, Australia

Focus: Improve balance and coordination, muscle strength, reaction time, and aerobic capacity.

Program Setting: Classes were conducted in local indoor lawn bowling and sports clubs that hosted community programs for various sports and exercise activities, comparable to community exercise, sports, and recreation facilities in the United States. Many lawn bowling and sports clubs also included other indoor attractions such as restaurants, meeting facilities, and movies.

Content: The classes were designed by a physical therapist (PT) to address physical fall risk factors: balance and coordination, strength, reaction time, and aerobic capacity. Each class began with five to ten minutes of warm-up that included stretching of the major lower limb muscle groups and ten minutes of cool-down that included gentle stretching, relaxation, and controlled-breathing practice. Each class included music chosen by the participants.

The classes included the following types of exercises:

• Balance and coordination exercises, including modified Tai Chi exercises, practice in stepping and in changing direction, dance steps, and catching and throwing a ball

• Strengthening exercises, including exercises that used the participant’s weight (e.g., sit-to-stand, wall press-ups) and resistance-band exercises that worked both upper and lower limbs

• Aerobic exercises, including fast-walking practice with changes in pace and direction

As the classes progressed, the complexity and speed of the exercises and the resistance of the bands were steadily increased.

Participants also took part in a home exercise program using content from the exercise class and recorded their participation in a home exercise diary.

Duration: A total of 37 one-hour classes were conducted once a week over a one-year period.

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SINGlE INTErVENTIONS: ExErCISE

Delivered by: Nationally accredited exercise instructors who had been trained to conduct this exercise program by a licensed PT (accredited by Australia’s National Association for Gentle Exercise). The study used currently accredited exercise leaders who already had a good understanding of the exercise principles.

Before classes began, regular meetings were held with the exercise leaders to discuss the content and how the classes would be run, giving the leaders ownership in the program. Training included approximately six hours of additional meetings, discussion, and practice sessions before beginning the program. During the classes, instructors were visited by the PT for support once each term.

Minimum Level of Training Needed: Information was not provided by the principal investigator.

Key Elements:

• This study used health practitioners to assess and recruit participants. General practitioners are in an ideal position to both identify older people at risk of falls and to support their participation in an exercise program when appropriate.

• The program used existing services and facilities in the community, so it is likely to be sustainable and transferable to other settings.

Available Materials: In addition to the guidance received during the exercise sessions, participants received:

• A home exercise program based on class content*

• A “hot tips” sheet listing practical strategies for avoiding falls such as where to place hands and feet if a loss of balance occurs*

* See Appendix C-1

Study Citation: Barnett A, Smith B, Lord S, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: A randomized controlled trial. Age and Ageing. 2003 Jul;32(4):407–14.

Contact Practitioners interested in using this intervention may contact the principal investigator for more information:

Anne Barnett, MPH Physiotherapy Department Bankstown Hospital, Locked Mailbag 1600 Bankstown NSW 2200, Australia

Tel: +61 (9) 722 7155 Fax: +61 (9) 722 7125 E-mail: [email protected]

mailto:[email protected]

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The Otago Exercise Program Campbell, et al. and Robertson, et al. (1997, 1999, 2001, 2005) This program, tested in four randomized controlled trials and one controlled multi-center trial, was an individually tailored program of muscle-strengthening and balance-retraining exercises of increasing difficulty, combined with a walking program. This extensively tested fall prevention program is now used worldwide.

Overall, the fall rate was reduced by 35 percent among program participants compared with those who did not take part. The program was equally effective for men and women. Participants aged 80 years and older who had fallen in the previous year showed the greatest benefit.

Note: This study has been translated for use in the United States. See page 11 for more information.

Population: Participants were aged 65 to 97 years and lived in the community.

Geographic Locale: Dunedin, New Zealand

Focus: Improve strength and balance with a simple, easy-to-implement, and affordable home-based exercise program.

Program Setting: The program was conducted in participants’ homes. It was intended for people who did not want to attend, or could not reach, a group exercise program or recreation facility.

Content: A physical therapist (PT) or nurse visited each participant at home four times over the first two months (at weeks one, two, four, and eight) and again for a booster session at six months. To maintain motivation, participants received telephone calls once a month during the months when no visits were scheduled.

The first home visit lasted one-hour and all subsequent visits took about half an hour. During each visit, the PT or nurse prescribed a set of in-home exercises (selected at appropriate and increasing levels of difficulty) and a walking plan.

The exercises included:

• Strengthening exercises for lower leg muscle groups using ankle cuff weights

• Balance and stability exercises such as standing with one foot in front of the other and walking on the toes

• Active range of motion exercises such as neck rotation and hip and knee extensions

Participant safety was ensured by tailoring the exercise program and by giving participants instructions and an illustration for each exercise.

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Duration: The exercises took about 30 minutes. Participants were encouraged to complete the exercises three times a week and to walk outside the home at least two times a week. Exercises then were continued on an ongoing basis. In three trials, the exercise program was prescribed for one year and in one trial it was extended to two years.

Delivered by: The program was delivered by either a PT experienced in prescribing exercises for older adults or a nurse who was given special training and received ongoing supervision from a PT.

Minimum Level of Training Needed: PTs can deliver the program immediately after reading the manual. Nurses can be trained to deliver the program after a two-day training program and with ongoing supervision by a PT.

Key Elements: PTs should understand the research evidence on which the program is based and avoid adding or subtracting exercises from the set used in the trials, as this particular combination of exercises worked to reduce falls.

Available Materials: The Otago Exercise Programme instruction guide, which describes the program exercises, is available to health professionals at www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/publications_promotion/prd_ctrb118334.pdf

Study Citation:

Primary studies

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal. 1997 Oct 25;315(7115):1065–9.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: A randomized controlled trial in women 80 years and older. Age and Ageing. 1999 Oct;28(6):513–8.

Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA. Randomised controlled trial of prevention of falls in people aged ≥75 with severe visual impairment: The VIP trial. British Medical Journal. 2005 Oct 8;331(7520):817–20.

Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697–701.

Robertson MC, Gardner MM, Devlin N, McGee R, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres. British Medical Journal. 2001 Mar 24;322(7288):701–4.

www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/publications_promotion/prd_ctrb118334.pdf

www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/publications_promotion/prd_ctrb118334.pdf

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Supplemental Articles Gardner MM, Buchner DM, Robertson MC, Campbell AJ. Practical implementation of an exercise-based falls prevention programme. Age and Ageing. 2001 Jan;30(1):77–83.

Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: A meta-analysis of individual-level data. Journal of the American Geriatrics Society. 2002 May;50(5):905–11.


M. Clare Robertson, PhD Research Honorary Associate Professor Department of Medicine, Dunedin School of Medicine University of Otago P.O. Box 913 Dunedin 9054, New Zealand

E-mail: [email protected]


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U.S. Program Contact

In 2011, CDC funded the translation of the Otago Exercise Program for dissemination and implementation in the U.S.

As implemented in the U.S., the key features of the Otago Exercise Program are:

1. Delivered only by PTs or PT assistants. 2. Provides a minimum of five visits over eight weeks with a follow-up visit at six months. 3. Takes place in the older adult’s home or in an outpatient setting.4. Encourages the PTs to find ways to help older adults adhere to the program. This may include

encouraging the caregiver to exercise with the older adult or having participants perform their Otago exercises in a group setting.

To support adoption of the Otago Exercise Program, CDC has published an implementation guide for PTs and has partnered with other organizations to develop:

• An online training program for PTs • Additional implementation resources (videos, handouts, etc.).

Available Materials: Tools to Implement the Otago Exercise Program in the U.S. are available at http://www.med.unc.edu/aging/cgec/exercise-program/tools-for-practice/

Online training is available at: http://www.med.unc.edu/aging/cgec/exercise-program.

Practitioners interested in learning more may contact:

Tiffany E. Shubert, MPT, PhD Senior research scientist Center for Health Promotion and Disease Prevention UNC Chapel Hill

Phone: (919) 360-1970 Email: [email protected] Or visit the course website at: http://www.med.unc.edu/

http://www.med.unc.edu/aging/cgec/exercise-program/tools-for-practice/

http://www.med.unc.edu/aging/cgec/exercise-program


http://www.med.unc.edu

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liFE (lifestyle approach to reducing Falls through Exercise)� Clemson, et al. (2012)This study evaluated the effectiveness of two exercise interventions to reduce falls: an integrated balance and strength training intervention that focused on embedding exercises into daily life (LiFE), and a structured balance and strength exercise program performed three times a week.

Both interventions were tailored for participants and increased in difficulty during the intervention. Only the LiFE program was effective in reducing falls. Participants in the LiFE program experienced 31 percent fewer falls compared to the control group.

Population: Participants were community-dwelling adults aged 70 or older who had experienced two or more falls or one fall with a self-reported injury in the previous 12 months. More than half were female.

Geographic Location: Sydney, Australia

Focus: Integrate balance and strength training exercises into daily activities.

Program Setting: Sessions were conducted in the participants’ homes.

Content: This program consisted of five to seven in-home sessions where an implementer (a physical therapist [PT], occupational therapist [OT], or exercise physiologist) worked with each participant to add seven balance strategies (e.g., reducing base of support) and seven strength training strategies (e.g., bending knees) to their daily activities. The implementer worked with participants to upgrade the exercises over the course of the intervention. For instance, standing with one foot placed in front of the other (tandem stand) uses the balance strategy, “reduce base of support” and can be upgraded to standing on one foot as the participant becomes better at balancing.

The initial session lasted about 90 minutes; all subsequent sessions lasted 40–60 minutes.

• During Session One, the implementer:

– Assessed the ability and daily activities of the participant.

– Chose and demonstrated one to two LiFE balance exercises and one to two LiFE strength exercises.

– Provided background on the principles behind challenging balance and strengthening muscles.

– Worked with the participant to develop an Activity Plan for how, when, and where the exercises would be performed.

– Provided the participant with the LiFE Participant manual that contains instructions and examples of LiFE balance and strength activities.

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• Encouraged the participant to plan and record where and when they would do each exercise.

• During Sessions two through five, the implementer:

• Encouraged participants to suggest how they could perform LiFE exercises during daily activities and how they might upgrade these exercises (i.e., make them more challenging over time).

• Provided a new Activity Plan for each session that included current exercises, upgraded exercises, and two to four new exercises.

• Reviewed and confirmed exercise techniques for safety.

• During two booster sessions, the implementer:

– Finished embedding the seven balance and seven strength LiFE strategies if they were not completed.

– Reviewed the participant’s current exercises and encouraged finding more opportunities to embed them in routines and to upgrade them.

– Emphasized performing the exercises safety.

– Encouraged participant to continue doing these new exercises.

Examples of LiFE Program exercises

Strategy Exercise Setting Upgraded exercise

Balance Training

Reduce base of supportTandem stand

Tandem walking

Brushing teeth

Ironing

Walking down the hallway

Standing on one leg

Move to the limits of sway

Lean to one side as far as possible

Talking on the telephone

Hold longer

Reduce base of support

Strength Training

Bend your knees Squatting instead of bending your back

Putting laundry away in drawers

Putting a plate away in the kitchen cupboard

Emptying the dishwasher

Put the dishwashing liquid on a lower shelf

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Duration: Training sessions were held once a week for five weeks with two booster sessions if needed. Sessions lasted 40–90 minutes. The implementer encouraged participants to do the prescribed exercises as often as possible each day over the course of the 12-month intervention period.

Delivered By: This program was delivered by a PT, OT, or exercise physiologist. Each participant worked with only one member of the intervention team. However, all of the implementers met regularly to discuss any issues and to contribute suggestions and upgrades for all participants.

Minimum Level of Training Needed: A PT, OT, or exercise physiologist experienced with the LiFE approach. Those interested in implementing the intervention MUST read the trainer’s manual and do the LiFE program themselves before teaching it to older adults. The therapist should understand the importance of planning, prompts, and practice to reinforce learning new habits.

LiFE does not prescribe a set number of times to do a LiFE activity. Rather it is focused on seeking opportunities to “do more.” The assessment and planning tools have been carefully designed to reflect this approach to behavior change.

Key Elements:

• Understanding the principles underlying the balance and strength exercises.

• Planning when, where, and how to incorporate the exercises, including using prompts.

• Understanding how to upgrade the exercises.

• Having the participant practice the exercises safely so they feel challenged over time.

• Working with the participant to develop and embed LiFE exercises into daily activities.

Available Materials: Clemson L, Fiatarone Singh M, Munro J. Lifestyle-Integrated Functional Exericse (LiFE) Program to reduce falls. Participant’s manual. Sydney: Sydney University Press; 2014.

Clemson L, Fiatarone Singh M, Munro J. Lifestyle-Integrated Functional Exericse (LiFE) Program to reduce falls. Trainer’s manual. Sydney: Sydney University Press; 2014.

The Daily Routine Chart, Life Assessment Tool, LiFE Balance and Strength Activity Planner’s and the Activity Plan are all freely downloadable from Sydney University Press: http://ses.library.usyd.edu.au/handle/2123/10627

Study Citation: Clemson L, Fiatarone Singh MA, Bundy A, Cumming RG, Manollaras K, O’Loughlin P, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ (Clinical research ed). 2012;345:e4547.

http://ses.library.usyd.edu.au/handle/2123/10627

http://ses.library.usyd.edu.au/handle/2123/10627

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Supplemental ArticleClemson L, Singh MF, Bundy A, Cumming RG, Weissel E, Munro J, Manollaras K, Black D. LiFE Pilot Study: A randomised trial of balance and strength training embedded in daily life activity to reduce falls in older adults. Aust Occup Ther J 2010;57(1):42–50


Lindy Clemson, PhD Associate Professor in Ageing, Head of Discipline (Occupational Therapy) Faculty of Health Sciences, The University of Sydney Cumberland Campus, PO Box 170 Lidcombe 1825, Australia



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Erlangen Fitness Intervention Freiberger, et al. (2007)This study examined two interventions to reduce falls: a psychomotor intervention that focused on body awareness, body experience, and coordination; and a fitness intervention that focused on functional skills, strength, endurance, and flexibility. Both interventions included group classes, home-based exercises, and physical activity recommendations.

Only the fitness intervention was effective in reducing falls. Compared to the control group, participants in the fitness group experienced 23 percent fewer falls.

Population: The participants were community-dwelling, physically active people in very good health, aged 70 or older. Slightly more than half were male.

Geographic Locale: Erlangen, Germany

Focus: Improve functional skills, strength, endurance, and flexibility.

Program Setting: The group classes were conducted at the University of Erlangen-Nuremberg, Institute of Sport Science. The home-based portion was carried out in participants’ homes.

Content: This program consisted of group exercise classes, home-based exercises, and recommendations for increasing physical activity levels such as walking or biking daily.

Each session lasted one hour. Approximately one-third of the time was spent on each of the components:

• Strength and flexibility training (including the use of dumbbells, ankle weights, weight-bearing exercises, and joint flexibility)

• Balance and motor coordination training (including standing balance, dynamic weight transfers, stepping strategies, motor control when performing activities of daily living, motor control under time pressure and sensory awareness)

• Endurance training (including normal walking and Nordic walking)

Group discussions were conducted at the beginning and end of each session to outline the goals of the program and to review progress.

Duration: One-hour classes were held twice a week for 16 weeks. In addition, participants were instructed to perform selected exercises at home on a daily basis between sessions and after the program ended.

Delivered by: The program was supervised by two trainers, preferably a man and a woman, who had backgrounds in sports science. This training is similar to that received by physical education teachers. It included knowledge of physical education, kinesiology, motor control, and motor learning. Trainers also had experience working with older persons, which they generally gained during the course of their academic studies.

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Minimum Level of Training Needed: Trainers need to have a background in physical therapy, psychology, sports science, or as a personal trainer. Trainers also need to have experience working with older adults and attend a two-day training session, or to attend a comprehensive four-day training if they do not have experience working with older adults.

Training should include age-related changes in physical, cognitive and social dimensions (e.g., changes in muscle mass, loss of strength and power); fear of falling and how to address it; how to perform the strength, balance, and gait training exercises; and an introduction to public health theories and models, such as the Health Belief Model.

Key Elements:

• Strength, endurance, and functional skill exercises, including balance and gait training, should increase in intensity over the duration of the program.

• Trainers must attend the program training.

Available Materials: A course manual has been published in German (Freiberger E, Schöne D. Sturzprophylaxe im Alter. Deutscher Aerzteverlag: Köln). In addition, there is a German web site with information about fall prevention and trainers’ education at www.standfestimalter.de.

Study Citation: Freiberger E, Menz HB, Abu-Omar K, Rütten A. Preventing falls in physically active community-dwelling older people: A comparison of two intervention techniques. Gerontology. 2007 Aug;53(5):298–305. Exercise-based Interventions

Supplemental Article Freiberger E, Menz HB. Characteristics of falls in physically active community-dwelling older people. Zeitschrift für Gerontologie und Geriatrie. 2006 Aug;39(4):261–7.


Ellen Freiberger PhD Associate Professor FAU Erlangen-Nürnberg Institute for Biomedicine of Aging Kobergerstr. 6090408 Nürnberg

Tel: +49(0)911- 5302-96162 Fax: +49(0)911-5302-96151 E-mail: [email protected]

www.standfestimalter.de


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Senior Fitness and Prevention (SEFIP)� Kemmler, et al. (2010)This study evaluated the effectiveness of an exercise intervention that consisted of two structured high-intensity group classes and two home exercise sessions per week. After 18 months, participants were 46 percent less likely to fall and 67 percent less likely to suffer a fall-related injury compared with those who did not receive the intervention.

Population: Participants were women aged 65 or older who lived in the community and were not taking medications that could affect bone health (e.g., bisphosphonates, hormone therapy).

Geographic Locale: Erlangen-Nuremberg, Germany

Focus: Determine the effect of high intensity exercise on falls, fractures, coronary heart disease (CHD) risk factors, and health care costs.

Program Setting: This program took place in community gymnasiums.

Content: This program consisted of high-intensity group exercise classes and a home-based exercise routine.

Each group session lasted 60 minutes and included four components:

1. A 20 minute warm-up/aerobic dance sequence with progressively higher-impact elements

2. A 5 minute period that included static and dynamic balance training

3. A 15 minute period that included functional gymnastics, isometric strength training, and stretching sequences

– Floor exercises for trunk , hip and leg muscles

– Exercises were replaced every 6 to 18 weeks by more strenuous ones.

4. A 15 minute circuit training period

a. Upper body exercises

– Low and high belt rowing

– Shoulder raises

– Continuous stretching using elastic belts (Thera-Band)

b. Dynamic weight-bearing leg exercises

The home exercise sessions emphasized strength and flexibility (including using Thera-bands). Every 12 weeks, the home exercises were made more difficult. The exercise trainer encouraged participants to practice their home exercises consistently.

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Duration: Two 60-minute group classes and two 20-minute home exercise sessions were conducted weekly. The intervention lasted 18 months.

Delivered by: This program was delivered by certified exercise instructors under the guidance of the principal investigator.

Minimum Level of Training Needed: Certified exercise instructors with experience teaching older adults.

Key Elements:

• Resistance exercises

• Exercises that include high impact elements

• Exercises to improve general coordination and balance

• Exercises that become more challenging over time.

Available Materials: None at this time.

Study Citation: Kemmler W, von Stengel S, Engelke K, Häberle L, Kalender WA. Exercise effects on bone mineral density, falls, coronary risk factors, and health care costs in older women: the randomized controlled senior fitness and prevention (SEFIP)study. Arch Intern Med. 2010 Jan 25;170(2):179–85.

Supplemental Articlevon Stengel S, Kemmler W, Engelke K, Kalender WA. Effects of whole body vibration on bone mineral density and falls: results of the randomized controlled ELVIS study with postmenopausal women. Osteoporosis International. 2011 Jan;22(1):317–25.


Wolfgang Kemmler, PhD Institute of Medical Physics University of Erlangen Henkestrasse 91, 91052 Erlangen, Germany

E-mail: [email protected].

mailto:

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Adapted Physical Activity Program Kovacs, et al. (2013)This study evaluated an exercise program adapted for older women. One-hour classes were held twice a week for 25 weeks. Exercises were tailored to each participant’s physical abilities and became more difficult as the study progressed.

Participants were 60 percent less likely to fall compared to those who did not receive the intervention.

Population: Participants were community-dwelling women aged 60 and older who had not exercised regularly in the past six months.

Geographic Location: Budapest, Hungary

Focus: Improve balance, decrease risk of falls, and improve quality of life.

Program Setting: The exercise program was conducted in the gymnasium of a local sports center.

Content: A physical therapist (PT) and a PT student assistant led a class of 30–38 participants. The PT encouraged participants to choose the music that was played during the structured exercises.

The exercises were tailored to the abilities of each participant and became more difficult over the 25-week intervention by increasing the number of repetitions or the duration. The PT increased the difficulty of the ball games by reducing the ball’s size and increasing the ball’s weight over the course of the intervention.

While participants exercised, the PT explained how the exercises related to movements used in everyday situations

Each class included:

• A 5–10 minute warm up that included stretching.

• A 20–25 minute period of structured exercises and functional activities.

– Exercises included raising arms over head while seated, partial squats, tandem stepping, and high stepping in place.

– Functional activities included sit to stand, stand to sit, and walking and turning.

• A 20–25 minute group activity such as a relay race or ball game. Participants choose which group activity they preferred for each session.

– Relay races included walking on toes, walking backward and stepping in and out of hoops as part of the course.

– Ball games included adapted basketball and an adapted form of catch.

• A 5–10 minute cool-down.

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Duration: Classes were held one-hour twice a week and lasted for 25 weeks.

Delivered By: A PT with extensive geriatric experience and assisted by a physical therapy student. PTs in Hungary must have a minimum of three years of supervised work before he/she is permitted to practice alone.

Minimum Level of Training Needed: This program should be delivered by a PT with three or more years of experience to ensure the effectiveness and safety of the program.

Key Elements:

• Exercise sessions should be held at least twice a week and continue for at least six months.

• Each session must include all components. Exercises should be tailored for participants with limited abilities (e.g. performed slower, doing fewer repetitions, using lighter objects and balls, or with support).

• Each session must include functional activities (e.g., sit to stand and stand to sit, walking, and stepping in different directions).

• Exercises should be accompanied by brief explanations about how the exercises relate to movements used in everyday situations.

Available Materials: A more detailed description of the structured and group exercises is available in the Appendix C-2.

Study Citation: Kovács E, Prókai L, Mészáros L, Gondos T. Adapted physical activity is beneficial on balance, functional mobility, quality of life and fall risk in community-dwelling older women: a randomized single-blinded controlled trial. Eur J Phys Rehabil Med. 2013 Jun;49(3):301–10.


Éva Kovács, PhD Faculty of Health Science, Semmelweis University 17 Vas street 1088—Budapest, Hungary

Tel: (+36 1) 486-4946 Email: [email protected]


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Tai Chi: Moving for better balance Li, et al. (2005) This study compared the effectiveness of a six-month program of Tai Chi classes with a program of stretching exercises. Participants in the Tai Chi classes had fewer falls and fewer fall injuries, and their risk of multiple falls was decreased 55 percent.


Population: Participants were inactive adults aged 70 or older. Three-quarters were female. All participants lived in the community.

Geographic Locale: Portland, Oregon, United States.

Focus: Improve balance and physical performance with Tai Chi classes designed for older adults.

Program Setting: The Tai Chi program was conducted in community settings such as local senior centers and adult activity centers.

Content: The program included 24 Tai Chi forms that emphasized weight shifting, postural alignment, and coordinated movements. Synchronized breathing aligned with Tai Chi movements was integrated into the movement routine.

Each session included instructions in new movements as well as a review of movements from previous sessions. Each practice session incorporated musical accompaniment.

Each hour-long session included:

• A 5- to 10-minute warm-up period

• Practice of Tai Chi movements

• A 5- to 10-minute cool-down period

Practicing at home was encouraged and monitored using a home-practice log.

Duration: One-hour classes were held three times a week for 26 weeks, followed by a six-month period in which there were no organized classes.

Delivered by: Experienced Tai Chi instructors who followed the classical Yang style, which emphasizes multidirectional weight shifting, body alignment, and coordinated movement of the arms, legs, and trunk.

Minimum Level of Training Needed: Instructors should be familiar with the fundamental principles of Tai Chi and the major postures and movements, be able to follow the training protocol, and have experience teaching physical activity to older adults.

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Key Elements:

• Program settings can include facilities such as senior centers, adult activity centers, and community centers.

• An average class size of 15 is ideal for effective learning and teaching.

• For this program to be successful, participants should attend Tai Chi classes at least two times a week and participate actively in class.

• Tai Chi can also be used in rehabilitative settings where the emphasis is on retraining balance in older adults.

Available Materials: No intervention materials were available at the time of publication.

Study Citation: Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, Wilson NL. Tai Chi and fall reductions in older adults: A randomized controlled trial. Journal of Gerontology. 2005 Feb;60A(2):187–94.


Fuzhong Li, PhD Oregon Research Institute 1715 Franklin Boulevard Eugene, OR 97403, United States

Tel: 541-484-2123 E-mail: [email protected]


In 2011, CDC funded the translation of the Moving for Better Balance exercise program for dissemination and implementation in the U.S.


Heather Hodge Director, Chronic Disease Prevention Programs Healthy Living YMCA OF THE USA 101 N Wacker Drive, Chicago IL 60606

Tel: 800 872 9622 x8287 Direct: 312 419 8287 Email: [email protected]



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Australian Group Exercise Program Lord, et al. (2003)This study evaluated a 12-month group exercise program for frail older adults. The program was tailored to each participant’s abilities. Overall, the fall rate was 22 percent lower among participants, and 31 percent lower among participants who had fallen in the previous year, compared with those who did not take part in the program.

Population: Ages ranged from 62 to 95 although nearly all were 70 years or older. Most study participants were female. Participants lived in retirement villages and most were independent.

Geographic Locale: Sydney and Wollongong, Australia

Focus: Increase participants’ strength, coordination, gait and balance, and increase their ability to carry out activities of daily living such as standing up from a chair and climbing stairs.

Program Setting: Programs were conducted in common rooms in residential care community centers and senior centers within the retirement villages.

Content: The group classes included weight-bearing exercises and balance activities that were challenging but not so difficult as to discourage participation or cause any adverse events. The program emphasized social interaction and enjoyment.

The program consisted of four successive three-month terms. The first term included understanding movement, how the body works, training principles, and basic exercise principles. This was followed by progressive strength training and increasingly challenging balance exercises, using equipment to maintain interest. In each term, the exercise sessions built on the skills acquired in the previous term.

Each one-hour class had three components:

• A 5- to 15-minute warm-up period that included chair-based activities, stretching large muscle groups, and later in the program, slow to moderate walking.

• A 35- to 40-minute conditioning period that included aerobic exercises, strengthening exercises, and activities to improve balance, hand-eye and foot-eye coordination, and flexibility.

As the program progressed, the number of repetitions of each exercise increased, beginning with four repetitions at week 2 and reaching 30 by week 10. Thirty repetitions were maintained for rest of the program.

• A 10-minute cool-down period that included muscle relaxation, controlled breathing, and guided imagery.

Duration: One-hour classes were held twice a week for 12 months. The program consisted of four successive three-month terms.

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Delivered by: Six exercise instructors were trained to deliver the program. All had previously completed a training course conducted by the Australian Council for Health, Physical Education and Recreation, on leading exercise programs for frail, older people. The project coordinator regularly observed the instructors to provide support and to monitor program fidelity and consistency.

Everyone involved in implementing the program received specific one-day training and met regularly to discuss issues and training updates.

Minimum Level of Training Needed: Instructors should have taken an exercise instructor course as well as a specific course on teaching exercise to older adults.

Key Elements: Information was not provided by the principal investigator.


Study Citation: Lord SR, Castell S, Corcoran J, Dayhew J, Matters B, Shan A, Williams P. The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: A randomized, controlled trial. Journal of the American Geriatrics Society. 2003 Dec;51(12):1685–92.


Stephen R. Lord, PhD Neuroscience Research Australia Barker Street, Randwick, Sydney NSW 2031, Australia



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Yaktrax® Walker McKiernan (2005)This study tested the effectiveness of the Yaktrax® Walker, a lightweight traction device that fits over shoes, to prevent falls among older adults when walking outdoors on ice and snow.

During the winter months, participants in the Yaktrax® intervention group were half as likely to slip and about 60 percent less likely to fall, compared to the group that wore their usual winter footwear. Participants in the intervention group also experienced significantly fewer minor fall-related injuries.

Population: Participants were community-dwelling adults aged 65 or older who had fallen at least once in the previous year. About 60 percent were female.

Geographic Locale: Rural central and northern Wisconsin, United States

Focus: Using a traction device that fits on shoes to improve stability when walking on ice and snow.

Program Setting: Participants used the Yaktrax® Walker on their own in the community.

Content: Participants were given a Yaktrax® Walker that was sized to fit the external length of their usual winter footwear. Participants had to be able to put on the Yaktrax® Walker correctly.

After reviewing the Yaktrax® Walker instruction manual with each participant, the research study coordinator spent approximately 30 minutes training the participant and then had the participant practice putting on the Yaktrax® Walker.

Participants were told to only wear the device outdoors when there was ice or snow. They were instructed that the Yaktrax® Walker should never be worn indoors or on smooth outdoor non-ice surfaces.

Duration: This study took place during the winter of 2003–04.

Delivered by: A research study coordinator.

Minimum Level of Training Needed: Instructors should read the manual and practice putting the Yaktrax® Walker on themselves and others.

Key Elements:

• People must be able to safely put on and take off the Yaktrax® Walker or leave the device on a dedicated pair of shoes or boots that are only worn out of doors.

Image 1: This image depicts the Yaktrax Walker over a pair of boots. Reprinted with permission of the Yaktrax® Walker. Yaktrax® is a Registered Trademark of Implus Footcare LLC.

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• Shoes should be measured to assure proper fit of Yaktrax® Walker.

• Yaktrax® Walker must not be worn indoors.

• Yaktrax® Walker should be inspected for breakage and replaced if broken.

Available Materials: Instructions that accompany the device are sufficient for consumer use.

Study Citation: McKiernan FE. A simple gait-stabilizing device reduces outdoor falls and non-serious injurious falls in fall-prone older people during the winter. Journal of the American Geriatrics Society. 2005 Jun;53(6):943–7.


Fergus Eoin McKiernan, MD Center for Bone Diseases Marshfield Clinic 1000 North Oak Avenue Marshfield, WI 54449, United States



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Veterans Affairs Group Exercise Program Rubenstein, et al. (2000) This study evaluated a structured group exercise program for fall-prone older men. At the end of the three-month program, participants were two-thirds less likely to fall compared with those who did not take part in the program.

Note: This study calculated the fall rate as the number of falls per hour of physical activity.

Population: All participants were aged 70 or older and lived in the community. All were males who had at least one of these fall risk factors: leg weakness; impaired gait, mobility, and/or balance; and/or had fallen two or more times in the previous six months.

Geographic Locale: Los Angeles, California, United States

Focus. Increase strength and endurance and improve mobility and balance using a low- to moderate-intensity group exercise program.

Program Setting: The program was conducted at a Veterans Affairs ambulatory care center.

Content:

• Strength training included hip flexion, extension, abduction, and adduction; knee flexion and extension; squats, dorsiflexion, and plantar flexion.

Over the first four weeks, participants increased each exercise from one to three sets of 12 repetitions.

Resistance levels also were increased progressively. The rate of progression was modified for subjects with physical limitations.

• Endurance training used bicycles, treadmills, and indoor walking sessions. Endurance training alternated between cycling (once a week), using a treadmill (twice a week), and indoor walking that included a walking loop as well as two flights of stairs (twice a week).

Heart rates were monitored to ensure that participants did not exceed 70 percent of their heart rate reserve.

• Balance training used a rocking balance board, balance beam, obstacle course, and group activities such as balloon volleyball and horseshoes.

Balance training sessions were held twice a week and increased in difficulty over the 12-week program.

Duration: Three 1½-hour sessions a week for 12 weeks.

Delivered by: Exercise physiology graduate students with training from experienced exercise physiologists or physical therapists (PTs).

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Minimum Level of Training Needed: Facilitators should have approximately two weeks of on-the-job training by an experienced exercise physiologist or PT.

Key Elements:

• Using a group format and providing a wide variety of exercise activities

• Focusing on strength, balance, and endurance

• Providing personal encouragement and reinforcement

Available Materials: No materials were available at time of publication.

Study Citation: Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO, Pietruszka FM, Robbins, AS. Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men. Journal of Gerontology: Medical Sciences. 2000 Jun;55A(6):M317–21.


Laurence Z. Rubenstein, MD, MPH, FACP Professor and Chairman, Donald W. Reynolds Department of Geriatric Medicine The Donald W. Reynolds Chair in Geriatric Medicine The University of Oklahoma, HSC 1122 NE 13th Street, ORB 1200Oklahoma City, Oklahoma 73117

Tel: 405.271.8124 Fax: 405.271.3887 Email: [email protected]


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Falls Management Exercise (FaME)� Intervention Skelton, et al. (2005) This study examined the effectiveness of an individualized, tailored group and home-based exercise intervention designed to improve participants’ dynamic balance and core and leg strength, and to recover their ability to get down to and up from the floor.

After 36 weeks, the fall rate in the exercise group was reduced by one-third. Over the entire study, which included a 50-week follow-up period, the fall rate was reduced by 54 percent.

Population: Participants were women aged 65 or older, living independently, who had fallen three or more times in the previous year.

Geographic Locale: London, United Kingdom

Focus: Improve balance and strength.

Program Setting: Group classes were conducted at four locations in London in Community Leisure Centers (gym facilities that have rooms for exercise classes). Home exercises were performed in participants’ homes.

Content: Before starting the program, participants were assessed for asymmetry in strength or balance and specific problems with strength, balance, and flexibility.

Five basic functional tests were used:

• Shoulder flexibility

• Hamstring flexibility

• Timed Up And Go

• 180 degree turn

• Functional Reach

Participants also received a health screening and were evaluated for fear of falling (FES-I), fracture risk (Black score), quality of life (SF12), and confidence in maintaining balance (ConfBal).

Falls Management Exercise (FaME) group classes were based on the Otago Exercise Programme, which includes exercises for endurance and flexibility as well as floor exercises. The exercises meet the American College of Sports Medicine guidelines for adults over age 65.

Class exercises were tailored to the abilities of the group and home exercises were tailored to each participant’s needs and abilities. All exercises became more challenging (that is, increased in intensity or difficulty) as the program progressed. For example, classes used individualized resistance bands and progressively reduced levels of support (seated and supported options moving to unsupported options).

Home exercises addressed asymmetry in strength or balance by prescribing additional repetitions or sets for the weaker side.

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Class exercises focused on:

• Improving first static then dynamic balance

• Muscle and bone strength (e.g., Thera-Bands, free weights, low-impact side stepping and standing squats, etc.)

• Endurance (e.g., marching, side stepping)

• Flexibility of five major muscle groups

• Gait (e.g., side and backward walking)

• Functional skills (e.g., sit to stand)

• How to avoid falling (e.g., compensatory stepping)

• Functional floor exercises (e.g., crawling, rolling, back extensions, and side leg lifts)

Note: These exercises were introduced after at least eight weeks of preparatory physical therapy to restore the skills needed to get down to and up off the floor.

The home exercise program consisted of:

• Warm-up

• 10-minute endurance session

• Otago exercises along with additional resistance-band strengthening exercises

• Developmental flexibility exercises

• Cool-down

Participants wore hip protectors during the exercise sessions in group classes and at home to reduce the risk of hip fractures. They were not encouraged to wear them at other times.

Duration:

• The pre-exercise assessment lasted about 40 minutes.

• One-hour group classes were held once a week for 36 weeks.

• 30 minutes of home exercises were done twice a week.

Delivered by: Postural Stability Instructors. These are qualified “exercise for the older person” instructors, physical therapists (PTs), and occupational therapists (OTs) who have taken the five-day training course, “Exercise for the Prevention of Falls and Injuries in Frailer Older People.”

Minimum Level of Training Needed: The United Kingdom has national education standards governing the training content for exercise instructors working with special populations, including older people. More information can be found at www.skillsactive.com/training/standards.

www.skillsactive.com/training/standards

www.skillsactive.com/training/standards

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After instructors are trained to work with older people, they can train as Postural Stability Instructors, focusing on older people at high risk of falling. PTs and OTs do not have to become an exercise instructor in order to take this training.

The five-day training course to become a Postural Stability Instructor is considered postgraduate-level training. It involves 54 contact hours of theory and practical delivery and 100 noncontact hours. The qualification is based on successfully completing a 40-minute practical exam, a case study on a faller, and a theoretical paper.

More information about the course content can be found at www.laterlifetraining.co.uk.

The United Kingdom Chartered Society of Physiotherapists endorses the Postural Stability Instructor training course. Additional information can be found at www.csp.org.uk.

Key Elements:

• To be successful, the exercise program should last at least 36 weeks.

• It should include a minimum of two hours per week of combined group and home exercises.

• Exercise must be progressive, continually increasing in intensity, resistance, weight, and challenging balance.

• Exercises must be tailored to each individual’s needs and abilities, both in group classes and at home.

• It is desirable but not essential to include floor work to reduce fear of falling and improve falls self-efficacy.

Available Materials: The participants’ home exercise booklet is available at http://www.ageuk.org.uk/documents/en-gb/id8950%20strength%20and%20balance%20book.pdf?dtrk=true

Information about the accredited Postural Stability Instructor course in the United Kingdom is available at www.laterlifetraining.co.uk.

The training manual for the Postural Stability Instructor course can be purchased from www.laterlifetraining.co.uk.

Study Citation: Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise—FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age and Ageing. 2005 Nov;34(6):636–9.

Supplemental Articles Skelton DA, Dinan SM. Exercise for falls management: Rationale for an exercise program aimed at reducing postural instability. Physiotherapy Theory and Practice. 1999 Jan;15(2):105–20. Available at: www.laterlifetraining.co.uk/documents/ExerciseFallsManage.PDF.

www.laterlifetraining.co.uk

www.csp.org.uk

http://www.ageuk.org.uk/documents/en-gb/id8950%20strength%20and%20balance%20book.pdf?dtrk=true

http://www.ageuk.org.uk/documents/en-gb/id8950%20strength%20and%20balance%20book.pdf?dtrk=true



www.laterlifetraining.co.uk/documents/ExerciseFallsManage.PDF

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Iliffe A, Kendrick D, Morris R, Skelton D, Gage H, Dinan S, Stevens Z, Pearl M, Masud T. Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: Protocol of the ProAct 65+ trial. Trials. 2010 Jan;11(1):6–10.

Skelton DA, Stranzinger K, Dinan SM, Rutherford O. BMD improvements following FaME (falls management exercise) in frequently falling women age 65 and over: An RCT. Journal of Aging and Physical Activity. 2008 Jul;16(Suppl):S89–90.

Skelton DA. The Postural Stability Instructor: Qualification in the United Kingdom for effective falls prevention exercise. Journal of Aging and Physical Activity. 2004 Jul;12(3):375–6.

Skelton DA. Effects of physical activity on postural stability. Age and Ageing. 2001 Nov;30 (Suppl 4):33–9.


Professor Dawn Skelton, PhD Professor of Ageing and Health, Centre for Living, Institute of Applied Health Research School of Health and Life Sciences Govan Mbeki Health Building, Glasgow Caledonian University Cowcaddens Road, Glasgow G4 0BA, United Kingdom

Tel: +44 (0) 141 331 8792 E-mail: [email protected]


34


Music-based Multitask Exercise Program Trombetti, et al. This study evaluated the effectiveness of Jaques-Dalcroze eurhythmics, a music-based multitask exercise program, to improve gait and balance and reduce falls among high risk older adults. Experienced instructors led a one-hour class once a week for six months. At the end of the six-month program, participants were 54 percent less likely to fall compared to those who did not participate in the program.

Population: Participants were community-dwelling adults aged 65 and older with an increased risk of falling, defined as having had one or more self-reported falls, balance impairment, or being physically pre-frail. Most participants were female.

Geographic Location: Geneva, Switzerland

Focus: Improve gait and balance using Jaques-Dalcroze eurhythmics classes modified for older adults.

Program Setting: Classes were conducted in common areas of residential retirement communities.

Content: A certified and experienced Jaques-Dalcroze instructor led each session and played the piano. The program included a combination of gait and balance movements, flexibility training, and coordinated movements of multiple joints (e.g., rotating a ball in your hand while moving your arms and walking).

Participants wore thin soled shoes. The instructor constantly changed the music so participants could not predict the rhythm and had to adapt their movements in response. The participants helped select the style of music played.

Each one-hour class had three segments:

A 5–10 minute warm-up that included stretching exercises.

A 40 minute core-content period composed of multitask and balance challenging exercises. Basic exercises consisted of walking in time to the music and responding to changes in the music’s rhythmic patterns. Upper body exercises included sequences using percussion instruments or balls.

Other typical exercises included quick reaction exercises, walking out of rhythm, and multidirectional weight shifting. Exercises gradually became more difficult over the six month period.

The instructor requested participants to maintain a high level of attention and respond quickly to verbal instructions and changes in the rhythm of the music.

A 5–10 minute cool-down period.

35


Duration: A one-hour class once a week for six months.

Delivered by: Certified exercise instructors experienced in teaching Jaques-Dalcroze eurhythmics to older adults.

Minimum Level of Training Needed: Instructors should be trained in Jaques-Dalcroze eurhythmics instruction and have experience teaching older adults.

Key Elements:

• This program should be led by an experienced Jaques-Dalcroze instructor.

• An average class size of 15-18 is ideal for effective learning and teaching.

• To maintain program fidelity, the program should not be altered.

Available Materials: Information about the Jaques-Dalcroze eurhythmics certification program in the United States is available at http://www.dalcrozeusa.org/

Study Citation: Trombetti A, Hars M, Herrmann FR, Kressig RW, Ferrari S, Rizzoli R. Effect of music-based multitask training on gait, balance, and fall risk in elderly people: a randomized controlled trial. Archives of Internal Medicine. 2011 Mar 28;171(6):525–33.

Supplemental Articles Wahli-Delbos M. La Rythmique Jaques-Dalcroze, un atout pour les seniors. Geneva: Editions Papillon; 2010.

Hars M, Herrmann FR, Fielding RA, Reid KF, Rizzoli R, Trombetti A. Long-term exercise in older adults: 4-year outcomes of music-based multitask training. Calcified Tissue International. 2014 Nov;95(5):393–404.

ContactPractitioners interested in using this intervention may contact the principal investigator for more information:

Dr. Andrea Trombetti Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland


http://www.dalcrozeusa.org


36


Central Sydney Tai Chi Trial Voukelatos, et al. (2007)This study evaluated the effectiveness of community-based Tai Chi programs to reduce falls among people aged 60 or older. One-hour classes were offered once a week for 16 weeks in community settings by experienced instructors who taught their regular programs using several styles of Tai Chi.

After the 24-week follow-up period, the fall rate among Tai Chi participants was one-third lower, and the rate of multiple falls was 46 percent lower, than the rates for participants who did not take Tai Chi.

Population: Participants were healthy people aged 60 or older who lived in the community. About 84 percent were female.

Geographic Locale: Sydney, Australia

Focus: Improve balance and reduce falls

Program Setting: Community Tai Chi classes were conducted at locations such as town halls and senior centers. Locations were based on accessibility (e.g., accessible by public transportation, room accessible without climbing stairs), geographic diversity, and options for no- or low-cost sustainability after the study was completed.

Content: The majority of classes used modified Sun-style Tai Chi although a small proportion used Yang-style Tai Chi or a mixture of several styles. Detailed information about Tai Chi styles was not collected.

Instructors followed a set of guidelines that focused on teaching physical activity to older people and contained suggestions about how to incorporate key elements, such as relaxation, into the Tai Chi program. Some classes had the option to buy a video and/or booklet about the type of Tai Chi they were learning.

Duration: One-hour per week for 16 weeks.

Delivered by: Experienced Tai Chi instructors or instructors experienced in teaching physical activity to older people.

Minimum Level of Training Needed: Instructors must have at least five years’ experience as a Tai Chi instructor or have experience teaching physical activity to older people and attend an intensive weekend workshop about the basic principles of Tai Chi.

Key Elements:

• Limit class size to 12 people to maximize the attention each participant can get from the instructor.

• Incorporate relaxation and lowered center of gravity exercises into each class.

37


• It is important that participants maintain an upright (straight) posture at all times to reduce the risk of falling. Forms of Tai Chi that require participants to squat while moving or to get into positions that are not totally upright should be modified appropriately.

• Instructors need to be aware of participants’ comfort levels as well as any medical or physical conditions that may limit their ability to perform certain Tai Chi movements.

• Tai Chi movements should be introduced gradually so that participants are not exposed to too many new movements at once.

Available Materials:

• Tai Chi Principles for Falls Prevention in Older People*

• Guidelines for Instructors Working with Older People*

*See Appendix C-3.

Study Citation: Voukelatos A, Cumming RG, Lord SR, Rissel C. A randomized, controlled trial of Tai Chi for the prevention of falls: The Central Sydney Tai Chi trial. Journal of the American Geriatrics Society. 2007 Aug;55(8):1185–91.

Supplemental Article Voukelatos A. The Central Sydney Tai Chi trial: A randomized controlled trial investigating the effectiveness of Tai Chi in reducing falls in older people. PhD thesis, University of Sydney, 2010.


Alexander Voukelatos, PhD School of Public Health and Community Medicine, University of New South Wales Health Promotion, Sydney Local Health District Level 9 (North), KGV building, Missenden Road Camperdown, New South Wales 2050, Australia

Tel: +61(0)2 9515 9079 Fax: +61(0)2 9515 9056 E-mail: [email protected]


38


Simplified Tai Chi Wolf, et al. (1996) This study compared a 15-week program of Tai Chi classes that used 10 simplified movements with a balance training program. After four months, the risk of falling more than once among participants in the Tai Chi classes was almost half that of people in the comparison group.

Participants reported that after the study they were better able to stop themselves from falling by using their environment and appropriate body maneuvers. After the study ended, almost half the participants chose to continue meeting informally to practice Tai Chi.

Population: All were 70 years or older and lived in the community. Most study participants were female.

Geographic Locale: Atlanta, Georgia, United States

Focus: Improve strength, balance, walking speed, and other functional measures among seniors using Tai Chi.

Program Setting: The program used facilities in a residential retirement community.

Content: Participants were taught a simplified version of Tai Chi. The 108 existing Tai Chi forms were synthesized into a series of 10 composite forms (see Appendix C-4) that could be completed during the 15-week period. The composite forms emphasized all elements of movement that generally become limited with age.

Exercises systematically progressed in difficulty. The progression of movements led to gradually reducing the base of standing support until, in the most advanced form, a person was standing on one leg. This progression also included increasing the ability to rotate the body and trunk as well as performing reciprocal arm movements. These exercises were led during the group sessions; however, individuals were encouraged to practice these forms on their own, outside of the group setting.

Duration: The 15-week program included:

• Twice weekly 25-minute group sessions

• Weekly 45-minute individual contact time with the instructor

• Twice daily 15-minute individual practice sessions at home without an instructor

Delivered by: A Tai Chi Quan grand master with 50 years of experience instructed the classes and met individually with participants. A nurse/coordinator maintained contact with participants to ensure their participation.

Image 1: This image depicts a Tai Chi form

39



Key Elements: This program needs to be led by a very experienced Tai Chi grand master. No elements should be changed in order to replicate these results among older adults who are similar to study participants.

Available Materials: Illustrations of the 10 Tai Chi exercises are in Appendix C-4.

Study Citation: Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society. 1996 May;44(5):489–97.

Supplemental Article Wolf SL, Coogler C, Xu T. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Archives of Physical Medicine and Rehabilitation. 1997 Aug;78(8):886–92.


Steven L. Wolf, PhD, PT, FAPTA Department of Rehabilitation Medicine Emory University School of Medicine 1441 Clifton Road NE Atlanta, GA 30322, United States

Tel: 404-712-4801 Fax: 404-712-5895 E-mail: [email protected]


40


Multi-target Stepping Program Yamada, et al. (2013)This study evaluated the effectiveness of a multi-target stepping (MTS) program with exercise compared to a walking program with exercise. Participants in the MTS program had fewer falls and fewer fall-related fractures. The fall rate was 65 percent lower among people who took part in the program compared to those who did not.

Population: Participants were community-dwelling adults aged 65 and older who could |walk independently and did not have severe cognitive impairment. Slightly more than half were female.

Geographic Location: Kyoto, Japan

Focus: Improve stepping performance, gait, balance, and control of foot movements.

Program Setting: An academic health center that included a fitness center for older adults.

Content: The MTS program consisted of stepping on colored squares in a prescribed order at the participant’s own pace. This was repeated four times each session. Participants attended sessions twice a week for 24 weeks.

An exercise trainer taped 15 rows of four inch paper squares onto a very thin (about 0.1 in), rubber mat 33 feet long by 3.3 feet wide. Each square was spaced two feet apart. A square with a new color was added every six weeks. The number of squares in each row increased from two to five over the course of 24 weeks.

• Weeks 1–6: two squares (red and blue)

• Weeks 7–12: three squares (red, blue, and yellow)

• Weeks 13–18: four squares (red, blue, yellow, and white)

• Weeks 19–24 five squares (red, blue, yellow, white, and green)

Each row contained at least two squares of different colors and their arrangement was randomized.

Participants stepped on the same color square during the entire course. The other colored square(s) served as distractors. Participants could step on the squares with either foot and were allowed to take as many steps as needed to reach their next target square. The course changed each week and became progressively more difficult.

In weeks 19–24In weeks 13–18In weeks 7–12In weeks 1–6

1 m

Reprinted with permission of the author.

10 m

This picture illustrates the progression of the 24-week MTS course

41


A physical therapist (PT) or exercise trainer instructed each participant, who wore flat-soled shoes, to walk through the course at their own pace. It typically took one to two minutes to complete the course. After each trial, the PT or exercise trainer provided feedback, such as “You missed the second square, please pay more attention the next time you try.”

Both intervention and control participants took part in a 30 minute exercise class twice a week that included mild strength training, balance and flexibility exercises.

Duration: The MTS sessions took seven minutes and were held twice a week for 24 weeks.

Delivered by: A PT and exercise trainer who were experienced in working with older adults. The main role of the PT was risk management in the event of a fall or other injury, although he also provided instruction and feedback. The exercise trainer did not receive any additional training for this intervention.

Minimum Level of Training Needed: Exercise instructors experienced in working with older adults.

Key Elements: The course should become gradually more difficult, based on the physical ability of each participant.

Available Materials: No intervention materials were available at publication.

Study Citation: Yamada M, Higuchi T, Nishiguchi S, Yoshimura K, Kajiwara Y, Aoyama T. Multitarget stepping program in combination with a standardized multicomponent exercise program can prevent falls in community-dwelling older adults: a randomized, controlled trial. Journal of the American Geriatrics Society. 2013;61(10):1669–75.

Supplemental ArticlesYamada M, Aoyama T, Arai H, Nagai K, Tanaka B, Uemura K, Mori S, Ichihashi N. Complex obstacle negotiation exercise can prevent falls in community-dwelling elderly Japanese aged 75 years and older. Geriatriatric Gerontology International. 2012 Jul;12(3):461–7.

Yamada M, Tanaka B, Nagai K, Aoyama T, Ichihashi N. Rhythmic stepping exercise under cognitive conditions improves fall risk factors in community-dwelling older adults: Preliminary results of a cluster-randomized controlled trial. Aging Mental Health. 2011 Jul 1;15(5):647–53.

Yamada M, Tanaka B, Nagai K, Aoyama T, Ichihashi N. Trail-walking exercise and fall risk factors in community-dwelling older adults: preliminary results of a randomized controlled trial. Journal of the American Geriatrics Society. 2010 Oct;58(10):1946–51.

42



Minoru Yamada, PhD Associate Professor Graduate School of Comprehensive Human Sciences, University of Tsukuba 3-29-1 Otsuka, Bunkyo-ku, Tokyo 112-0012, Japan

Tel: +81-3-3942-6863 Fax: +81-3-3942-6895 E-mail: [email protected]


43


The following three tables summarize the study population characteristics, study methodology, and intervention

characteristics of the 15 Single Interventions focused on exercise.

44

A CDC COMPENDIUM OF EFFECTIVE FALL INTERVENTIONS: WHAT WORKS FOR COMMUNITY-DWELLING OLDER ADULTS Ta

ble

1.

Su

mm

ary

Tab

le o

f S

tud

ies

and

Stu

dy

Po

pu

lati

on

Stud

yN

o . S

tud

y Pa

rtic

ipan

tsM

ean

Age

%

Fem

ale

Rac

e/Et

hnic

ity

Soci

oeco

nom

ic S

tatu

s (S

ES)

Prev

ious

Fal

lsO

ther

C

hara

cter

isti

cs

Barn

ett 2

003

163

7567

%90

% u

sed

En

glis

h as

pr

imar

y

lang

uage

Stud

y co

nduc

ted

in

low

SES

are

as42

% fe

ll in

pas

t yea

r27

% li

ved

alon

e

Cam

pbel

l 199

723

384

100%

Mos

t wer

e W

hite

20%

use

d co

mm

unit

y se

rvic

es44

% fe

ll in

pas

t yea

r

Clem

son

2012

317

8355

%M

ost w

ere

whi

te46

% e

duca

tion

>hi

gh

scho

ol (H

S)90

% h

ad fa

ll w

/ inj

ury

in p

ast y

ear

Frei

ber

ger 2

007

152

7539

%10

0% W

hite

33%

edu

cati

on >

HS

Mea

n in

com

e

$5,4

58/m

onth

34%

fell

in p

ast 6

m

onth

s

Kem

mle

r 201

024

669

100%

NA*

NA

Fall

rate

=0.

39 fa

lls/

per

son

in 6

mon

ths

bef

ore

stud

y

Kova

cs 2

013

7668

100%

100%

Whi

te58

% >

12

year

s ed

ucat

ion

38%

fell

in p

ast y

ear

Li 2

005

256

7770

%90

% W

hite

92%

edu

cati

on ≥

HS

68%

inco

me

<$35

,000

37%

fell

in p

ast 3

m

onth

s48

% li

ved

alon

e

Lord

200

355

180

86%

100%

Whi

teN

A34

% fe

ll in

pas

t yea

r22

% in

ass

iste

d liv

ing

hous

ing

McK

iern

an 2

005

113

7460

%10

0% W

hite

NA

100%

fell

in p

ast y

ear

Rub

enst

ein

2000

5975

0%95

% W

hite

63%

edu

cati

on >

HS

56%

fell

in p

ast 6

m

onth

s73

% m

arri

ed

Skel

ton

2005

8173

100%

Mos

t wer

e W

hite

Mos

t wer

e re

tire

d he

alth

care

wor

kers

w/ a

t le

ast s

ome

HS

educ

atio

n

100%

≥3

falls

in

past

yea

rM

ean

num

ber

of

med

icat

ions

=4

15%

use

d ca

nes

Trom

bet

ti 2

011

134

7696

%10

0% W

hite

79%

edu

cati

on <

HS

55%

fell

in p

ast y

ear

Vouk

elat

os 2

007

702

6984

%M

ost w

ere

Whi

te44

% e

duca

tion

≥H

S34

% fe

ll in

pas

t yea

r

Wol

f 199

620

076

81%

Mos

t wer

e W

hite

77%

edu

cati

on >

HS

36%

fell

in p

ast y

ear

Yam

ada

2013

264

7767

%10

0% A

sian

NA

34%

fell

in p

ast y

ear

*No

info

rmat

ion

avai

labl

e

45


Tab

le 2

. S

tud

y M

eth

od

olo

gy

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Barn

ett 2

003

Sout

hwes

t Syd

ney,

Aus

tral

iaRe

crui

ted

whi

le p

atie

nts

in

gene

ral p

ract

ice

clin

ics

or

atte

ndin

g ho

spit

al-b

ased

ph

ysic

al th

erap

y cl

inic

s

Age

≥65

& >

1 ph

ysic

al

impa

irm

ent a

ssoc

iate

d w

/ fal

l ris

k (lo

wer

lim

b w

eakn

ess,

poo

r bal

ance

, sl

ow re

acti

on ti

me)

Cogn

itiv

ely

impa

ired

or

had

deg

ener

ativ

e or

med

ical

con

diti

ons

that

pre

clud

ed

part

icip

atin

g in

an

exer

cise

pro

gram

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Post

al s

urve

ys s

ent t

o pa

rtic

ipan

ts e

ach

mon

th. I

f no

t rec

eive

d w

ithi

n 2

wee

ks,

part

icip

ant w

as in

terv

iew

ed

by te

leph

one.

12 m

onth

sFa

ll ra

te

IRRa =

0.60

(0.3

6–0.

99)

Non

e

Fall

w/ i

njur

y ra

teIR

Ra =0.

66 (0

.38–

1.15

)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Cam

pbel

l 199

7D

uned

in, N

ew Z

eala

ndW

omen

regi

ster

ed w

ith

a ge

nera

l pra

ctic

e in

Dun

edin

w

ere

invi

ted

by g

ener

al

prac

titi

oner

to ta

ke p

art

Age

>80

& a

ble

to m

ove

arou

nd w

ithi

n th

eir o

wn

hom

e

Cogn

itiv

ely

impa

ired

or

rece

ivin

g ph

ysic

al

ther

apy

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

giv

en 1

2 pr

e-ad

dres

sed

& s

tam

ped

m

onth

ly fa

ll ca

lend

ar

pos

tcar

ds. I

f one

was

not

re

ceiv

ed, p

arti

cipa

nt w

as

inte

rvie

wed

by

tele

phon

e.

12 m

onth

sFa

ll ra

te

RRb=

0.67

(p<

0.05

) 92

% e

duca

tion

≥

HS

68%

inco

me

<$35

,000

Firs

t fal

lH

Rc =0.

81 (0

.56–

1.16

)

Firs

t fal

l wit

h in

jury

HRc=

0.61

(0.3

9–0.

97)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

46

A CDC COMPENDIUM OF EFFECTIVE FALL INTERVENTIONS: WHAT WORKS FOR COMMUNITY-DWELLING OLDER ADULTS St

udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Clem

son

2012

Sydn

ey, A

ustr

alia

Vete

rans

, sp

ouse

s &

war

w

idow

s re

crui

ted

by

mai

lings

to D

epar

tmen

t of

Vete

ran’

s A

ffai

rs d

atab

ase

in S

ydne

y &

3 g

ener

al

data

base

s.

Age

≥70

, ≥2

falls

or o

ne

fall

w/ i

njur

y in

pas

t 12

mon

ths

Mod

erat

e or

sev

ere

cogn

itiv

e im

pair

men

t, la

ck o

f con

vers

atio

nal

Engl

ish,

inab

ility

to

am

bula

te

inde

pen

dent

ly,

neur

olog

ical

con

diti

on

that

sev

erel

y im

pact

ed

gait

/mob

ility

, nur

sing

ho

me

resi

denc

e, o

r te

rmin

al il

lnes

s

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Dai

ly c

alen

dar m

aile

d m

onth

ly w

ith

blin

ded

follo

w-u

p te

leph

one

calls

to

non-

resp

onde

rs

12 m

onth

sFa

ll ra

te (s

truc

ture

d vs

co

ntro

l) IR

Rc =0.

81 (0

.56–

1.17

) O

ne p

atie

nt

in s

truc

ture

d ex

erci

se h

ad

groi

n st

rain

; O

ne L

iFE

part

icip

ant

had

a p

elvi

c st

ress

frac

ture

Fall

rate

(LiF

E vs

con

trol

)IR

Rc =0.

69 (0

.48–

0.99

)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Frei

ber

ger 2

007

Erla

ngen

, Ger

man

yRe

crui

ted

from

a h

ealt

h in

sura

nce

com

pany

m

emb

ersh

ip d

atab

ase

Age

≥70

, com

mun

ity-

dwel

ling,

& a

ble

to w

alk

inde

pen

dent

ly

Una

ble

to w

alk

inde

pen

dent

ly o

r co

gnit

ivel

y im

pair

ed

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

cale

ndar

s. If

no

t ret

urne

d, p

arti

cipa

nt

rece

ived

a fo

llow

-up

tele

phon

e ca

ll. If

a fa

ll oc

curr

ed, t

he p

arti

cipa

nt

was

inte

rvie

wed

by

tele

phon

e.

12 m

onth

sN

umb

er o

f fal

lers

RR

d=

0.77

(0.6

0–0.

97)

NA

Num

ber

of m

ulti

ple

falle

rs

RRd=

0.87

(0.7

5–1.

01)

Fall

rate

RR

b=

0.64

(0.3

8–1.

06)

Tim

e to

firs

t fal

l (fi

tnes

s vs

co

ntro

l)33

7 ±

9 da

ys v

s. 2

16

±15

days

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

47


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Kem

mle

r 201

0Er

lang

en-N

urem

ber

g,

Ger

man

yM

emb

ers

of S

iem

ens

Hea

lth

Insu

ranc

e re

crui

ted

by m

ail

bet

wee

n M

ay 2

005

and

Janu

ary

2006

Age

≥65

, liv

ing

inde

pen

dent

lyH

isto

ry o

f alc

ohol

ism

or

Cus

hing

’s sy

ndro

me,

use

of

med

icat

ions

(b

isph

osph

onat

e,

horm

one

ther

apy,

gl

ucoc

orti

coid

s &

la

xati

ves)

that

aff

ect

bon

e m

etab

olis

m o

r fa

ll ri

sk, i

nfla

mm

ator

y di

seas

e, s

econ

dary

os

teop

oros

is, p

ast

part

icip

atio

n in

an

exer

cise

stu

dy, v

ery

low

phy

sica

l cap

acit

y,

or p

arti

cipa

tion

in

spor

ts in

pas

t 10

year

s

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Fall

cale

ndar

s w

/ mon

thly

te

leph

one

calls

for n

on-

resp

onde

rs

18 m

onth

sFa

ll Ra

teRR

d=

0.6

0 (0

.47–

0.76

) N

one

Num

ber

of f

alle

rs

RRa =

0.54

(0.3

5–0.

84)

Num

ber

of f

alle

rs w

/inj

ury

RRa =

0.33

(0.1

5–0.

74)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Kova

cs 2

013

Buda

pes

t, H

unga

ryRe

crui

ted

by a

n ad

vert

isem

ent i

n a

loca

l ne

wsp

aper

Age

≥60

, com

mun

ity

dwel

ling.

Pe

rson

al d

octo

r did

no

t rec

omm

end,

ne

urol

ogic

al d

isea

se,

card

iova

scul

ar d

isea

se,

seve

re lo

wer

lim

b pa

in, o

r par

tici

pate

d in

an

exer

cise

pro

gram

in

pas

t 6 m

onth

s

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

diar

y 6

mon

ths

Num

ber

of f

alle

rs

RRa =

0.4

0(0.

17–0

.92)

Non

e

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

48


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Li 2

005

Sydn

ey &

Wol

long

ong,

A

ustr

alia

Resi

dent

s of

sel

f-ca

re

& in

term

edia

te-c

are

reti

rem

ent v

illag

es th

at

atte

nded

info

rmat

ion

sess

ions

& th

en w

ere

appr

oach

ed in

divi

dual

ly

Age

≥62

Cogn

itiv

ely

impa

ired

, had

a

med

ical

con

diti

on

that

pre

vent

ed

part

icip

atio

n in

an

exer

cise

pro

gram

, or

alr

eady

att

ende

d ex

erci

se c

lass

es o

f eq

uiva

lent

inte

nsit

y

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Com

plet

ed m

onth

ly

ques

tion

nair

es. I

f not

re

ceiv

ed w

ithi

n a

wee

k af

ter

end

of th

e m

onth

, rec

eive

d a

hom

e vi

sit o

r tel

epho

ne

call.

Nur

sing

sta

ff a

t eac

h in

term

edia

te-c

are

site

als

o ke

pt a

falls

reco

rd b

ook.

12 m

onth

sFa

ll ra

te

RRd=

0.78

(0.6

2–0.

99)

Non

e

Fall

rate

for p

arti

cipa

nts

w/

no fa

lls a

t bas

elin

e RR

d=

0.88

(0.6

5–1.

20)

Fall

rate

for p

arti

cipa

nts

w/

falls

at b

asel

ine

RRd=

0.69

(0.4

8–0.

99)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

McK

iern

an 2

005

Rura

l Cen

tral

& N

orth

ern

Wis

cons

in, U

nite

d St

ates

Recr

uite

d us

ing

a da

taba

se

of p

eopl

e w

ho h

ad fa

llen

in th

e pa

st y

ear &

bee

n tr

eate

d in

a c

linic

or E

D,

one

dire

ct m

ailin

g, o

r an

anno

unce

men

t in

loca

l pri

nt

med

ia

Age

≥65

, com

mun

ity-

dwel

ling,

fell

in p

ast y

ear,

ambu

lato

ry w

/o a

wal

king

ai

d, c

apab

le o

f put

ting

on

Yakt

rax®

Wal

ker &

usi

ng

it a

ppro

pria

tely

, abl

e &

w

illin

g to

mai

ntai

n a

fall

diar

y

Inca

pabl

e of

wal

king

w

/o a

wal

king

aid

or

unab

le to

use

Yak

trax

® W

alke

r cor

rect

ly

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

kep

t a fa

ll di

ary

that

they

sub

mit

ted

at th

e en

d of

the

stud

y.

10,7

24 o

bser

vati

on-d

ays

Out

door

slip

RR=

0.50

(0.2

6–0.

96)

Non

e

Out

door

fall

RR=

0.45

(0.2

3–0.

85)

Out

door

fall

on d

ay

wal

ked

on s

now

or i

ceRR

=0.

42 (0

.26–

0.92

)

Out

door

inju

riou

s fa

llRR

=0.

10 (0

.02–

0.53

)

Out

door

inju

riou

s fa

ll on

da

y w

alke

d on

sno

w o

r ice

RR=

0.13

(0.0

3–0.

66)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

49


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Rub

enst

ein

2000

Los

Ang

eles

, Cal

iforn

ia,

Uni

ted

Stat

esM

ale

pati

ents

at V

A

Am

bula

tory

Car

e Ce

nter

re

crui

ted

thro

ugh

flye

rs &

te

leph

one

scre

enin

g

Age

>70

, am

bula

tory

, ha

d at

leas

t 1 o

f 4 ri

sk

fact

ors

(low

er e

xtre

mit

y w

eakn

ess,

impa

ired

gai

t, im

pair

ed b

alan

ce, o

r >1

fall

in p

ast 6

mon

ths)

Exer

cise

d re

gula

rly,

ca

rdia

c or

pul

mon

ary

dise

ase,

dem

enti

a,

term

inal

illn

ess,

se

vere

join

t pai

n,

unre

spon

sive

, de

pres

sion

, or

prog

ress

ive

neur

olog

ic d

isea

se

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Que

stio

ned

abou

t fal

ls &

in

juri

es e

very

2 w

eeks

by

phon

e or

in-p

erso

n

12 w

eeks

(at e

nd o

f in

terv

enti

on)

Act

ivit

y-ad

just

ed fa

ll ra

teRR

e =0.

37 (p

=0.

027)

Non

e

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Skel

ton

2005

Lond

on, U

nite

d Ki

ngdo

mPo

ster

s, lo

cal &

nat

iona

l ne

wsp

aper

s, lo

cal r

adio

st

atio

ns

Fem

ale,

age

≥65

, ≥3

falls

in

past

yea

rA

cute

rheu

mat

oid

arth

riti

s, u

ncon

trol

led

hear

t fai

lure

or

hyp

erte

nsio

n,

sign

ific

ant c

ogni

tive

im

pair

men

t, si

gnif

ican

t ne

urol

ogic

al d

isea

se

or im

pair

men

t, or

pr

evio

usly

dia

gnos

ed

oste

opor

osis

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Falls

dia

ries

wer

e re

turn

ed

ever

y 2

wee

ks b

y m

ail.

Ever

y fa

ll w

as fo

llow

ed u

p by

te

leph

one

to d

eter

min

e th

e ci

rcum

stan

ces

& o

utco

me.

20 m

onth

sFa

ll ra

teIR

Rc =0.

66 (0

.49–

0.90

) N

one

Fall

w/i

njur

y ra

teIR

Rc =0.

60 (0

.33–

1.07

)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

50


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Trom

bet

ti 2

011

Gen

eva,

Sw

itze

rlan

dRe

crui

ted

from

the

loca

l co

mm

unit

y th

roug

h m

ulti

ple

stra

tegi

es

incl

udin

g ad

vert

isem

ents

in

loca

l new

spap

ers

Age

≥65

, com

mun

ity

dwel

ling,

no

exp

erie

nce

w/ J

aque

s-D

alcr

oze

eurh

ythm

ics

exce

pt d

urin

g ch

ildho

od, i

ncre

ased

risk

of

falli

ng (≥

1 fa

lls, b

alan

ce

impa

irm

ent d

efin

ed a

s a

scor

e >2

on

Tine

tti t

est,

or

phys

ical

frai

lty)

Neu

rolo

gica

l di

seas

e as

soci

ated

w

/ mot

or d

efic

it o

r or

thop

edic

dis

ease

th

at s

igni

fican

tly

affe

cts

gait

/ba

lanc

e, a

med

ical

co

ndit

ion

such

as

term

inal

illn

ess,

or

fully

dep

ende

nt o

n as

sist

ive

devi

ce

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Fall

diar

y m

aile

d m

onth

ly to

st

udy

coor

dina

tor.

Follo

w-

up p

hone

cal

ls w

ere

mad

e to

non

-res

pon

ders

12 m

onth

sRi

sk fo

r >1

fall

RRd=

0.61

(0.3

9–0.

96)

Non

e

Risk

for ≥

2 fa

llsRR

d=

0.19

(0.0

6–0.

63)

Fall

rate

IRRa =

0.46

(0.2

7–0.

79)

Tim

e to

firs

t fal

lH

Rc =0.

53 (0

.30–

0.94

)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Vouk

elat

os 2

007

Sydn

ey, A

ustr

alia

Recr

uite

d th

roug

h ad

vert

isem

ents

in lo

cal

com

mun

ity

new

spap

ers

Age

>60

, had

not

pr

acti

ced

Tai C

hi in

pas

t 12

mon

ths

Deg

ener

ativ

e ne

urol

ogic

al

cond

itio

n, d

emen

tia,

se

vere

ly d

ebili

tati

ng

stro

ke, s

ever

e ar

thri

tis,

m

arke

d vi

sion

im

pair

men

t, or

una

ble

to w

alk

acro

ss a

room

un

aide

d

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

reco

rded

falls

da

ily &

mai

led

cale

ndar

s to

st

udy

coor

dina

tor m

onth

ly.

If no

t rec

eive

d w

ithi

n 2

wee

ks a

fter

the

end

of th

e m

onth

, the

par

tici

pant

was

co

ntac

ted

by te

leph

one.

24 w

eeks

Num

ber

of f

alls

A

n in

stru

ctor

tr

ied

to h

elp

a pa

rtic

ipan

t in

to a

m

ovem

ent &

th

e pa

rtic

ipan

t tw

iste

d a

ligam

ent.

Aft

er 1

6 w

eeks

follo

w-u

pIR

Ra =0.

73 (0

.50–

1.07

)

Aft

er 2

4 w

eeks

follo

w-u

pIR

Ra =0.

67 (0

.47–

0.94

)

Part

icip

ants

w/ ≥

2 fa

lls

afte

r 24

wee

ks fo

llow

-up

RRd=

0.54

(0.2

8–0.

96)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

51


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Wol

f 199

6A

tlan

ta, G

eorg

ia, U

nite

d St

ates

Com

mun

ity

seni

ors

&

resi

dent

s of

an

inde

pen

dent

liv

ing

faci

lity,

recr

uite

d th

roug

h ad

vert

isem

ents

&

dire

ct c

onta

ct

Age

≥70

, am

bula

tory

, w

illin

g to

par

tici

pate

w

eekl

y fo

r 15

wee

k pr

ogra

m &

at 4

-mon

th

follo

w-u

p

Seve

re c

ogni

tive

im

pair

men

t or

debi

litat

ing

cond

itio

n su

ch a

s m

etas

tati

c ca

ncer

, Par

kins

on’s

dise

ase,

str

oke,

or

prof

ound

vis

ual

defic

its

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

cal

enda

r or

mon

thly

pho

ne c

alls

from

st

aff.

7–20

mon

ths

Fall

risk

RRd=

0.53

(0.3

2–0.

86)

Non

e

≥1 fa

lls w

/ inj

ury

RRd=

0.81

(0.3

3–2.

02)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

52


ble

3.

Inte

rven

tio

n C

har

acte

rist

ics

Stud

yFo

cus

Prov

ider

sSt

ruct

ure

Num

ber

of S

essi

ons

Prov

ider

Con

tact

Ti

me

Barn

ett 2

003

Exer

cise

pro

gram

to im

prov

e ba

lanc

e, c

oord

inat

ion,

str

engt

h,

reac

tion

tim

e, &

aer

obic

cap

acit

y

Acc

redi

ted

exer

cise

in

stru

ctor

s tr

aine

d to

pr

ovid

e in

terv

enti

on

Gro

up e

xerc

ise

clas

ses

37 w

eekl

y 1-

hour

cl

asse

sCl

asse

s: 3

7 ho

urs

Cam

pbel

l 199

7Im

prov

e st

reng

th &

bal

ance

w

/ sim

ple

hom

e-ba

sed

exer

cise

pr

ogra

m

Phys

ical

ther

apis

t or n

urse

One

-on-

one

exer

cise

tr

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53


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cus

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ses:

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ours

55

Home ModificationToC3


Home ModificationThe VIP Trial Campbell, et al (2005) 56

Home Visits by an Occupational Therapist Cumming, et al (1999) 58

Falls-HIT (Home Intervention Team) Program Nikolaus, et al (2003) 60

Home Assessment and Modification Pighills, et al (2011) 62

Table 1 Summary Table of Studies and Study Population 65



56


The VIP Trial Campbell, et al. (2005) This study looked at the effectiveness of two interventions to reduce falls and fall injuries in older people with poor vision. The home safety program consisted of a home hazard assessment by an occupational therapist (OT) followed by home modifications and recommendations for behavior change. The home exercise program consisted of a combination of strength and balance exercises (the Otago Exercise Program modified for people with poor vision) plus vitamin D supplements.

Only the home safety program was effective in reducing falls. The home safety group had 61 percent fewer falls and 44 percent fewer injuries compared to those who received social visits.

Population: Participants were community-dwelling seniors aged 75 or older with poor vision. Two-thirds of the participants were female.

Geographic Locale: Dunedin and Auckland, New Zealand

Focus: Assess and reduce home hazards and encourage changes in behavior.

Program Setting: The program took place in participants’ homes.

Content: An OT conducted a home safety assessment and made suggestions for modifications. The assessment consisted of a walk-through of the participant’s home using a checklist to identify hazards. It included a discussion about items, behavior, or lack of equipment that could lead to falls. The OT and participant then agreed on which recommendations to implement.

The OT helped the participant obtain any necessary equipment and oversaw payment for the home modifications. Home modifications and equipment costing more than NZ$200 were funded by the local Board of Health and items costing less were funded by the participant or from research funds. The OT made a follow-up visit if equipment needed to be installed.

Duration: The intervention consisted of one or two home visits. The first visit lasted about two hours. If the OT needed to approve new equipment, she made a second visit two to three weeks later. The second visit lasted about 45 minutes.

Delivered by: OTs who attended a two-day training course.

Minimum Level of Training Needed: One half-day training is necessary for OTs to become familiar with the specific focus on falls prevention among people with poor vision.

Key Elements:

• The OT’s advice rather than the environmental changes was key.

• A trained and experienced OT is critical to the success of this intervention.

57

SINGlE INTErVENTIONS: HOME MODIFICATION

Available Materials: The Westmead Home Safety Assessment checklist is available but not the modified version used in the VIP trial.

Clemson L. Home fall hazards: A guide to identifying fall hazards in the homes of elderly people and an accompaniment to the assessment tool, the Westmead Home Safety Assessment (WeHSA). West Brunswick, Victoria: Co-ordinates Publications, 1997.

Study Citation: Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ. Randomised controlled trial of prevention of falls in people aged ≥75 with severe visual impairment: The VIP trial. British Medical Journal. 2005 Oct 8;331(7520):817–25.

Supplemental Article La Grow SJ, Robertson MC, Campbell AJ, Clarke GA, Kerse NM. Reducing hazard related falls in people 75 years and older with significant visual impairment: How did a successful program work? Injury Prevention. 2006 Oct;12(5):296–301.


M. Clare Robertson, PhD Research Honorary Associate Professor Department of Medicine, Dunedin School of Medicine University of Otago, P.O. Box 913 Dunedin 9054, New Zealand

Tel: +64 (3) 474 7007 extension 8508 Fax: +64 (3) 474 7641 E-mail: [email protected]

mailto:clare.robertson%40otago.ac.nz?subject=

58


Home Visits by an Occupational Therapist Cumming, et al. (1999)This study used an occupational therapist (OT) who visited participants in their homes, identified environmental hazards and unsafe behaviors, and recommended home modifications and behavior changes.

Fall rates were reduced by one-third but only among men and women who had experienced one or more falls in the year before the study.

Population: All participants were 65 or older and lived in the community. More than half of the participants were female.


Focus: Assess and reduce home hazards.

Program Setting: The program was conducted in participants’ homes.

Content: The OT visited each participant’s home and conducted an assessment using the standardized Westmead Home Safety Assessment form (see Available Materials below). The OT identified environmental hazards such as slippery floors, poor lighting, and rugs with curled edges, and discussed with the participant how to correct these hazards.

Based on standard occupational therapy principles, the OT also assessed each participant’s abilities and behaviors, and how each functioned in his or her home environment. Specific unsafe behaviors were identified such as wearing loose shoes, leaving clutter in high-traffic areas, and using furniture to reach high places. The OT discussed with each participant ways to avoid these unsafe behaviors.

Two weeks after the initial home visit the OT telephoned each participant to ask whether they had made the modifications and to encourage them to adopt the recommended behavioral changes.

Duration: One-hour home visit with a follow-up telephone call two weeks later. Total contact time was approximately two hours.

Delivered by: An OT with two years of experience.

Minimum Level of Training Needed: A degree in occupational therapy is the minimum qualification needed to conduct the home assessments, develop the recommendations, and supervise the home modifications.

59


Key Elements:

• Using an experienced OT is critical.

• These researchers emphasized that this study should not be used to justify widespread, untargeted home modification programs implemented by people who do not have skills in caring for older people.

Available Materials: Information on the falls prevention kit, which includes the Westmead Home Safety Assessment form and a booklet that gives background information on falls and hazards can be purchased from the following company:

Co-ordinates Therapy Services PO Box 59, West Brunswick Victoria 3055, Australia


Study Citation: Cumming RG, Thomas M, Szonyi M, Salkeld G, O’Neill E, Westburg C, Frampton G. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society. 1999 Dec;47(12):1397–1402.


Robert G. Cumming, PhD School of Public Health, Building A27 University of Sydney Sydney NSW 2006, Australia


mailto:jenny%40therapybookshop.com?subject=

mailto:robert.cumming%40sydney.edu.au?subject=

60


Falls-HIT (Home Intervention Team)� Program Nikolaus, et al. (2003) This study provided home visits to identify environmental hazards that can increase the risk of falling, provided advice about possible changes, offered assistance with home modifications, and provided training in using safety devices and mobility aids.

The fall rate for participants was reduced 31 percent. The intervention was most effective among those who had experienced two or more falls in the previous year; the fall rate for these participants was reduced 37 percent.

Population: Participants were frail community-dwelling older adults who had been hospitalized for conditions unrelated to a fall and discharged to home. Participants showed functional decline, especially in mobility. All were 65 or older and lived in the community. Three-quarters were female.

Geographic Locale: Mid-sized town, Southern Germany

Focus: Assess and reduce fall hazards in participants’ homes.

Program Setting: Intervention team members contacted patients once or twice while they were hospitalized to explain the program. The program took place in participants’ homes.

Content: The first home visit was conducted while the participant was still hospitalized. Two team members, an occupational therapist (OT) with either a nurse or a physical therapist (PT), depending on patient’s anticipated needs, conducted a home assessment. They identified home hazards using a standardized home safety checklist and determined what safety equipment a participant needed.

During two to three subsequent home visits, an OT or nurse met with the participant to:

• Discuss home hazards

• Recommend home modifications

• Facilitate necessary modifications

• Teach participants how to use safety devices and mobility aids when necessary

Duration: The program consisted of two or more home visits, each lasting about 1½ hours. After the participant was discharged from the hospital, three home visits typically were needed to provide advice on recommended home modifications and to teach the participant how to use safety devices and mobility aids. On average, the total individual contact time was eight hours.

61


Delivered by: The home intervention team was composed of a PT, OT, three nurses, a social worker, and a secretary. OTs generally worked with all participants. Depending on individual need, either a PT or nurse also helped the participant. The social worker was available to provide information about ambulatory services and to help participants complete applications for additional money from the mandatory care insurance.


Key Elements: Participants met all intervention team members at the hospital before they were discharged, which facilitated follow-up.

Available Materials: A standardized home safety checklist is available in German only.

Study Citation: Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): Results from the randomized falls-HIT trial. Journal of the American Geriatrics Society. 2003 Mar;51(3):300–5.


Thorsten Nikolaus, MD Medical Director/CEO Bethesda Geriatric Clinic and Professor of Geriatric Medicine University of Ulm Zollernring 26, 89073 Ulm, Germany

Tel: +49 731 187 185 Fax: +49 731 187 389 E-mail: [email protected]

mailto:jenny%40therapybookshop.com?subject=

62


Home Assessment and Modification Pighills, et al. (2011)This study examined the effectiveness of home assessment and modification to reduce falls. The intervention was delivered in the participants’ homes by either an occupational therapist (OT) or by a home care worker (HCW). After identifying potential home hazards and risky behaviors, the OT or HCW discussed their findings with the participant. Together they agreed on specific home modifications and behavior changes.

The intervention was only effective when it was implemented by OTs. Fall rates were reduced 46 percent among those who received home assessments by OTs.

Population: Participants were community-dwelling adults aged 70 or older who had fallen in the past year. About two-thirds of participants were female.

Geographic Location: Yorkshire, England.

Focus: Assess and reduce home hazards and unsafe behaviors that increased fall risk.

Program Setting: The intervention occurred in participants’ homes.

Content: An OT visited each participant’s home and conducted an assessment using the Westmead Home Safety Assessment (WeHSA) as a guide. The WeHSA identifies 72 categories of hazards and provides a comprehensive list of items and behaviors that the OT should identify. During the visit, the OT observed the participant performing daily activities in the home and identified behaviors that could increase fall risk.

The OT and participant discussed the identified hazards and behaviors and worked together to generate mutually acceptable solutions. The OT provided a written summary of the agreed upon recommendations to the participant and made referrals for equipment if needed.

The OT called the participant after four weeks to determine if he or she was following the recommendations.

Duration: Each home assessment lasted 1½–2 hours.

Delivered by: OTs who attended a half day training course. The course trainer, an OT with 19 years of experience, used the WeHSA to assess a video of a sample patient carrying out activities in their own home. The OTs were instructed to use the principles outlined in the WeHSA to evaluate the safety of the person in their home, shown in the video, and to suggest modifications.

The professional experience of the OTs ranged from less than a year to more than 20 years.

Minimum Level of Training Needed: A degree in occupational therapy.

63


Key Elements:

• Conduct a functional assessment. The OT should observe the older adult perform tasks in their home.

• Acknowledge the older adult’s capacity to act independently and to make his or her own choices.

• Determine modifications and changes jointly with the older adult.

Available Materials: Clemson L. Home fall hazards: A guide to identifying fall hazards in the homes of elderly people and an accompaniment to the assessment tool, the Westmead Home Safety Assessment (WeHSA). West Brunswick, Victoria: Co-ordinates Publications, 1997.

Study Citation: Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. Journal of the American Geriatrics Society. 2011;59(1):26–33.


Alison Pighills, PhD Education and Research Centre (K Block) Mackay Base Hospital P.O Box 5580 Mackay Mail Centre Mackay, Queensland 4741, Australia

Tel: (07) 4885 7081 E-mail: [email protected]

mailto:Alison.Pighills%40health.qld.gov.au?subject=

64



characteristics for the four single focused interventions highlighting home modification

65


Tab

le 1

. S

um

mar

y Ta

ble

of

Stu

die

s an

d S

tud

y P

op

ula

tio

n

Stud

yN

o . S

tud

y Pa

rtic

ipan

tsM

ean

Age

%

Fem

ale

Rac

e/Et

hnic

ity

Soci

oeco

nom

ic S

tatu

s (S

ES)

Prev

ious

Fal

lsO

ther

C

hara

cter

isti

cs

Cam

pbel

l 200

539

184

68%

99%

Eur

opea

n

0.3%

Mao

ri

0.5%

Oth

er

NA*

45%

fell

in p

ast y

ear

53%

live

d al

one

10%

rece

ived

hom

e he

alth

(per

sona

l ca

re) s

ervi

ces

84%

age

-rel

ated

m

acul

ar

dege

nera

tion

43%

cat

arac

t

3% d

iab

etic

re

tino

path

y

15%

gla

ucom

a

Cum

min

g 19

9953

077

57%

100%

Whi

teN

A31

% fe

ll in

pas

t yea

r37

% u

sed

a w

alki

ng

aid

Nik

olau

s 20

0336

082

73%

98%

Whi

teN

A30

% ≥

2 fa

lls in

pas

t ye

arA

ll sh

owed

fu

ncti

onal

dec

line,

es

pec

ially

in

mob

ility

Pigh

ills

2011

238

7967

%10

0% W

hite

NA

100%

≥2

falls

in p

ast

year

*No

info

rmat

ion

avai

labl

e

66


ble

2.

Stu

dy

Met

ho

do

log

y

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Cam

pbel

l 200

5 D

uned

in a

nd A

uckl

and,

New

Ze

alan

dPa

rtic

ipan

ts id

enti

fied

fr

om R

oyal

New

Zea

land

Fo

unda

tion

of t

he B

lind,

un

iver

sity

and

& h

ospi

tal

low

vis

ion

clin

ics,

&

opht

halm

olog

y pr

acti

ces

Age

>75

, poo

r vis

ion

(vis

ual a

cuit

y 6/

24 o

r w

orse

)

Una

ble

to w

alk

arou

nd

own

hom

e, c

urre

ntly

re

ceiv

ing

phys

ical

th

erap

y, o

r una

ble

to u

nder

stan

d st

udy

requ

irem

ents

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Pre-

paid

, add

ress

ed, t

ear-

off

mon

thly

pos

tcar

d ca

lend

ars.

In

dep

ende

nt a

sses

sors

ca

lled

part

icip

ants

to re

cord

ci

rcum

stan

ces

of fa

lls &

any

re

sult

ing

inju

ries

.

12 m

onth

sFa

ll ra

te

IRRa =

0.3

9 (0

.24–

0.62

) N

one

Fall

w/ i

njur

y ra

teIR

Ra = 0

.56

(0.3

6–0.

87)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Cum

min

g 19

99Sy

dney

, Aus

tral

iaRe

crui

ted

whi

le a

hos

pita

l pa

tien

t or a

mon

g p

eopl

e at

tend

ing

outp

atie

nt c

linic

s or

a lo

cal s

enio

r cen

ter

Age

≥ 6

5 &

am

bula

tory

Cogn

itiv

ely

impa

ired

&

not

livi

ng w

/ so

meo

ne w

ho c

ould

gi

ve in

form

ed c

onse

nt

& re

por

t fal

ls, o

r pl

anne

d to

hav

e a

hom

e as

sess

men

t by

an

occu

pati

onal

th

erap

ist

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

falls

cal

enda

r wer

e co

mpl

eted

dai

ly &

retu

rned

by

mai

l eac

h m

onth

. If

not r

ecei

ved

w/i

n 10

day

s,

part

icip

ant w

as c

onta

cted

by

tele

phon

e.

12 m

onth

sFa

ll ra

te fo

r par

tici

pant

s

w/ n

o fa

lls a

t bas

elin

e RR

b = 1

.03

(0.7

5–1.

41)

Non

e

Fall

rate

for p

arti

cipa

nts

w

/ fal

ls a

t bas

elin

eRR

b = 0

.64

(0.5

0–0.

83)

a Inci

denc

e Ra

te R

atio

b R

elat

ive

Rate

c H

azar

d Ra

tio

d Rel

ativ

e Ri

sk

67


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Nik

olau

s 20

03M

id-s

ized

tow

n, S

outh

ern

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Clinical


Clinical Three-Year Study of Vitamin D (Cholecalciferol) Plus Calcium Bischoff-Ferrari, et al (2006) 70

Psychotropic Medication Withdrawal Campbell, et al (1999) 72

Active Vitamin D (Calcitriol) as a Falls Intervention Gallagher, et al (2007) 74

VISIBLE (Visual Intervention Strategy Incorporating Bifocal and Long-distance Eyewear) Study Haran, et al (2010) 76

Vitamin D to Prevent Falls After Hip Fracture Harwood, et al (2004) 79

Cataract Surgery Harwood, et al (2006) 81

Pacemaker Surgery Kenny, et al (2001) 83

Study of 1000 IU Vitamin D Daily for One Year Pfeifer, et al (2009) 85

Quality Use of Medicines Program Pit, et al (2007) 87

Podiatry & Exercise Intervention Spink, et al (2011) 90

Table 1 Summary Table of Studies and Study Population Characteristics 94



70


Three-Year Study of Vitamin D (Cholecalciferol)� Plus Calcium Bischoff-Ferrari, et al. (2006) This study evaluated the effectiveness of administering a three-year vitamin D (cholecalciferol) and calcium supplementation program in reducing falls among older adults. Although the study included both men and women, the intervention was only effective among women. After three years, women in the intervention group were 46 percent less likely to fall once compared to women who did not participate in the program.

Population: Participants were community-dwelling adults aged 65 or older.

Geographic Location: Boston, Massachusetts

Focus: Investigate the effectiveness of long term vitamin D and calcium supplementation on falls.

Program Setting: A study center at a research institution.

Content: Research staff met with participants at the beginning of the study to perform an initial assessment. They collected medical history, height and weight, blood, and information on nutrition, physical activity, tobacco use, and alcohol use. Participants were provided with a six-month supply of 700 IU of vitamin D and 500 mg of calcium supplements and told to take them once daily at bedtime. Participants visited the study center every six months to repeat the assessment and to receive additional supplements.

Duration: Participants visited the study center once every six months; a visit lasted 2–3½ hours. They took vitamin D and calcium supplements daily for three years.

Delivered by: A research manager and research assistants delivered the intervention. A physician developed the intervention, trained the research coordinators, and provided technical assistance.

Minimum Level of Training Needed: This intervention could be delivered by a nurse’s aide or other allied health professional within a clinical setting.

Key Elements: A dose of 700 IU taken orally every day. Adhering to the scheduled supplementation is critical.


Study Citation: Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year randomized controlled trial. Archives of Internal Medicine. 2006 Feb 27;166(4):424–30.

71

SINGlE INTErVENTIONS: ClINICAl


Bess Dawson-Hughes, MD Senior Scientist and Director Bone Metabolism Laboratory Tufts University


72


Psychotropic Medication Withdrawal Campbell, et al. (1999) This study tested the effectiveness of psychotropic medication withdrawal and/or a home-based exercise program in reducing falls among older adults. Only the medication withdrawal was effective at reducing falls. Participants who had their psychotropic medications withdrawn were 64 percent less likely to fall compared with the comparison group.

Population: Participants were community-dwelling adults aged 65 or older who were currently taking a psychotropic medication (defined as a benzodiazepine or other hypnotic drug, antidepressant, or major tranquilizer) and whose general practitioner thought they might benefit from psychotropic medication withdrawal.

Geographic Location: Dunedin, New Zealand

Focus: Reduce psychotropic medication use among older adults.

Program Setting: Initial assessments were performed at home and in a research clinic. The trial medications were provided to participants in their homes.

Content: General practitioners (GP) identified patients they thought could benefit from discontinuing psychotropic medications. These were defined as benzodiazepines, other hypnotic drugs, antidepressants, and major tranquilizers. The research trial GP completed a physical examination and provided a basic overview. A research nurse collected baseline data on patients’ current medications and history of falls.

A pharmacist reformulated each psychotropic medication into capsules to prevent participants and the researchers from knowing who was receiving the withdrawal intervention. The control participants received their own active medication at the original dose throughout the trial. For participants randomized to the withdrawal group, all psychotropic medications were reduced gradually over 14 weeks by diluting active ingredients with an inert substance on the following schedule:

• Start of study: 100 percent active medication

• At 2 weeks: 80 percent active medication




• From 14 weeks until the end of the trial, capsules contained no active medication.

To implement this intervention in a community setting, physicians would prescribe a gradual reduction in dose and/or frequency over time to help their patients withdraw successfully.

73


Although this study did not include a counselling component, the authors noted that a psychologist should be involved to help participants adjust to issues such as changing sleep patterns.

Duration: The GP conducted the initial assessment by the trial at a clinic visit. A research nurse conducted an initial assessment at the participant’s home that lasted a half-hour. Medication was tapered off gradually over 14 weeks.

Delivered by: A GP explained the interventions. A nurse assessed fall history and current medication use. A pharmacist reformulated the medications.

Minimum Level of Training Needed: A physician with background knowledge about medications that increase falls risk.

Key Elements: Gradually withdrawing rather than suddenly stopping psychotropic medications.

Available Materials: The 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is available at http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf

Study Citation: Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: A randomized controlled trial. Journal of the American Geriatrics Society. 1999 Jul;47(7):850–3.

Contact Practitioners interested in using this intervention may contact the co-investigator for more information:

M. Clare Robertson, PhD Honorary Research Associate Professor Department of Medicine Dunedin School of Medicine University of Otago P.O. Box 913 Dunedin 9054, New Zealand


74


Active Vitamin D (Calcitriol)� as a Falls Intervention Gallagher, et al. (2007) This study evaluated the effectiveness of three different supplementation interventions at reducing falls. Participants were assigned to hormone therapy, hormone therapy and active vitamin D supplementation (0.25 µg [micrograms] calcitriol twice daily), or active vitamin D supplementation alone. Only the active vitamin D supplementation group experienced a reduced rate of falls. After three years, women who took active vitamin D supplements experienced 38 percent fewer falls than women who did not.

Population: Participants were community-dwelling women. The average age of participants was 72 at the start of the intervention.

Geographic Location: Omaha, Nebraska

Focus: Investigate the effectiveness of long term active vitamin D supplementation on falls.


Content: Research coordinators met with participants at the beginning of the study to perform an initial assessment. They conducted a physical examination and collected medical history and information on nutrition. Participants were given a six-month supply of 0.25 µg calcitriol and were instructed to take them twice daily. Participants visited the study center at six and twelve weeks and then every six months for follow-up assessments and to receive additional supplements.

Duration: Participants visited the study center once every six months; a visit lasted 45–60 minutes. Participants took active vitamin D supplements twice daily for three years.

Delivered by: All research coordinators were trained by a physician and had a college degree (bachelors). An endocrinologist oversaw the intervention. A physician wrote a prescription of calcitriol for each participant.

Minimum Level of Training Needed: Allied health professionals, with the supervision of a physician could conduct the assessments and provide information about vitamin D supplementation. A physician would be needed to prescribe calcitriol and to monitor any side effects.



Study Citation: Gallagher JC, Fowler S, Sherman SS. Combination treatment with estrogen and calcitriol in the prevention of Age-Related Bone Loss. Journal of Clinical Endocrinology and Metabolism 86:3618–3628, 2001.

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Supplemental ArticlesGallagher JC, Rapuri PB, Smith LM. An age related decrease in creatinine clearance is associated with an increase in number of falls in untreated women but not in women receiving calcitriol treatment. Journal of Clinical Endocrinology and Metabolism. 2007 Jan 92:51–58, 2007.

Gallagher JC, Rapuri P, Smith L. Falls are associated with decreased renal function and insufficient calcitriol production by the kidney. Journal of Steroid Biochemistry and Molecular Biology. 2007 Mar;103(3–5):610–3.


J Christopher Gallagher, MD Department of Endocrinology Creighton University School of Medicine 601 N 30th St, Suite 6718 Omaha, NE-68131

Tel: 402-280-4518 Fax: 402-280-4517 Email: [email protected]

76


VISIblE (Visual Intervention Strategy Incorporating bifocal and long-distance Eyewear)� Study Haran, et al. (2010)This study tested the effectiveness of an optometry intervention that provided older adults who normally used multifocal lenses with single lens distance glasses to wear outdoors. Although falls were not reduced among participants overall, falls were decreased 40 percent among participants who regularly took part in outdoor activities. Outdoor falls increased among participants who did not regularly engage in outdoor activities.

Population: Participants were high risk community-dwelling adults aged 65 or older. Participants were considered high risk if they had fallen in the previous 12 months, scored ≥15 seconds on the Timed Up and Go test, or were aged 80 or older. About 65 percent were female.

Geographic Location: Sydney and Illawarra, Australia

Focus: Increase use of single lens distance glasses for outdoor activities among older adults who normally wear multifocal glasses

Program Setting: An optometrist’s office

Content: During an initial visit an optometrist:

• Performed a standard visual assessment

• Recorded participant’s current type of glasses

• Updated the current multifocal prescription as needed

• Prescribed single lens distance glasses

• Encouraged use of transition or tinted distance lenses

At the second visit, approximately one-month later, the optometrist:

• Dispensed and fitted new glasses

• Demonstrated how multifocal glasses can cause falls by distorting depth perception and limiting the ability to see obstacles. . The optomestrist:

– Had participants look at images through the upper and lower portion of their multifocal lenses and through single distance lenses (depth perception and visual contrast tests)

– Showed photographs of street scenes and steps with and without simulated blurred lower field to reinforce how multifocal glasses may increase fall risk.

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• Advised using single lens glasses for most walking and standing activities, in particular:

– Walking up or down outdoor stairs

– Walking outside, in shopping centers, and in unfamiliar buildings (e.g., other people’s homes)

– Exiting public transport or personal vehicles

• Discouraged single lens distance glasses for:

– activities inside their own home,

– seated tasks,

– driving, and

– low risk tasks that require changes in depth of focus while standing or walking (e.g., cooking and shopping at the supermarket).

• Provided a reminder card and instruction booklet

Duration: The initial visit lasted 15–20 minutes and the second visit was about 30 minutes. Participants were encouraged to wear their single lens glasses while outdoors for the duration of the intervention.

Delivered by: An optometrist conducted all initial study visits and the majority of second visits. If this optometrist was unavailable, an alternative optometrist, research assistant, or study investigator conducted the education and counselling component of the second visit.

Minimum Level of Training Needed: An optometrist is needed to prescribe distance glasses to eligible candidates. Either an optometrist or optical technician could fit the glasses. An optical technician with 1-hour of additional training could perform the activities carried out during the second visit. Counselling and education could be delivered by an optometrist or optical technician, or, with additional training, by a person with allied health, nursing, or a medical background.

Key Elements:

• Applying this intervention only to people who leave their homes daily.

• Educating and counselling participants about the importance of using single lens glasses to prevent falls outdoors.

• Using the streetscape photographs to reinforce how multifocal lenses affect depth perception and perceived contrast.

• Providing wallet cards and pamphlets as memory aids for some participants.

Available Materials: Pictures of the depth perception and visual contrast tests, the photographs of street and step scenes, and the contents of the wallet card are located in Appendix C-5

78


Study Citation: Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. British Medical Journal (Clinical research ed). 2010;340:c2265.


Dr. Mark Haran Rehabilitation Physician Royal North Shore Hospital, Sydney Australia

Ph. 612-94629333 Fax 612-99064301 Email: [email protected]

mailto:mharan%40med.usyd.edu.au?subject=

79


Vitamin D to Prevent Falls After Hip Fracture Harwood, et al. (2004)This study evaluated the effectiveness of vitamin D supplementation with or without calcium in reducing falls among older women. Participants received either a single injection of D2 (300,000 IU) and no calcium, a single injection of D2 (300,000 IU) with daily oral calcium supplementation (1 g), or a daily oral dose of D3 (800 IU) with calcium (1 g). After 1 year, participants who received the intervention were 52 percent less likely to fall compared to those who received no supplementation. Not enough women participated to detect differences in effectiveness by the type of vitamin D received.

Population: Participants were community-dwelling women aged 65 or older who underwent surgery for a hip fracture.

Geographic Location: Nottingham, United Kingdom

Focus: Investigate the effects of different vitamin and calcium supplementation regimens on bone mineral density, serum vitamin D, serum parathyroid hormone, and on rate of falls among older women who have fractured their hip.

Program Setting: A geriatric rehabilitation ward.

Content: A research nurse met with participants within seven days of surgery for a hip fracture to assess bone mineral density and to collect medical history, height and weight, blood, and information on nutrition, physical activity, tobacco use, and alcohol use. The nurse provided participants with either a single injection of D2 (300,000 IU) and no calcium, a single injection of D2 (300,000 IU) plus a month’s prescription of oral calcium (500 mg tablets to take twice daily) or with a month’s prescription of combined oral 800 IU vitamin D and 1 g calcium.

The research team contacted the participant’s general practitioner to inform them of the plan of care, and request that they prescribe the study dose of oral supplements and avoid prescribing additional vitamin D or other osteoporosis drugs during the intervention. The participant’s general practitioner prescribed one to three month supplies of oral supplements at a time. Patients took their own tablets, or were supervised by family members or home care workers to do so. Participants visited the study center at 3, 6, and 12 months post hip surgery to report falls.

Duration: The initial visit lasted an hour. Follow-up visits occurred at 3, 6, and 12 months and lasted 15 minutes. Participants who received oral supplements took them daily for a year.

Delivered by: A research nurse and general practitioner.


80


Key Elements:

• Vitamin D supplementation after hip fracture improves bone mineral density one year later and reduces falls incidence.

• Oral calcium supplementation is required as well as vitamin D.

• Three hundred thousdand IU vitamin D2 does not give adequate supplementation for a whole year.


Study Citation: Harwood RH, Sahota O, Gaynor K, Masud T, Hosking DJ; Nottingham Neck of Femur (NONOF) Study. A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study. Age Ageing. 2004;33(1):45–51.


Professor Rowan H. Harwood Nottingham University Hospitals NHS Trust & University of Nottingham

Email: [email protected]

mailto:rowan.harwood%40nuh.nhs.uk?subject=

81


Cataract Surgery Harwood, et al. (2006)This study evaluated the effectiveness of first eye cataract surgery in reducing falls compared with a control group who were awaiting surgery. After 12 months, participants in the intervention group had experienced 34 percent fewer falls than those who did not have cataract surgery.

Population: Participants were women aged 70 or older with cataract who had no prior eye surgery.

Geographic Location: Nottingham, United Kingdom

Focus: Determine if first cataract surgery reduces falls.

Program Setting: This intervention was conducted in either an ophthalmologist’s office or an optometrist-led cataract clinic.

Content: An optometrist assessed patients for cataracts during routine visits and if eligible, referred them to the study. An initial assessment was conducted one to two weeks later. During the assessment, an ophthalmic research nurse collected the participant’s medical (e.g., history of falls, depression) and ophthalmic (i.e., use of glasses, eye problems) history and conducted a full eye exam.

An ophthalmologist performed the cataract surgery by phacoemulsification and implanted a silicon intraocular lens within three weeks after the initial assessment. Ninety-nine percent of women had local anesthetic and the surgery lasted 15–30 minutes. The ophthalmologist reassessed the participant’s vision four weeks after surgery.

Duration: The initial assessment took 60 minutes. The cataract surgery lasted 15–30 minutes.

Delivered by: An ophthalmic research nurse conducted the initial assessment and vision tests. An ophthalmologist performed the surgery

Minimum Level of Training Needed: An ophthalmologist would be needed to perform cataract surgery. The vision tests could be performed by an optometrist or optometry technician.

Key Elements:

• Assess for cataracts during routine visits.

• Early surgery is beneficial for operable cataract.


Study Citation: Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. British Journal of Ophthalmology. 2005 Jan;89(1):53–9.

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Supplemental ArticleFoss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following second eye cataract surgery: a randomized controlled trial. Age Ageing. 2006 Jan;35(1):66–71.


Professor Rowan H. Harwood Nottingham University Hospitals NHS Trust & University of Nottingham


mailto:rowan.harwood%40nuh.nhs.uk?subject=

83


Pacemaker Surgery Kenny, et al. (2001)This study evaluated the effectiveness of surgical insertion of a dual chamber pacemaker at reducing falls among older adults with cardioinhibitory carotid sinus hypersensitivity (CSH). After 12 months, participants in the intervention group experienced 58 percent fewer falls than those who did not have the surgery.

Population: Participants were community-dwelling adults aged 50 or older with cardioinhibitory CSH and who had gone to the emergency department because of an unexplained fall. Mean age of participants was 73. More than half were women.

Geographic Location: Newcastle Upon Tyne, United Kingdom

Focus: Determine if cardiac pacing reduces falls among older adults with CSH.

Program Setting: This intervention took place in the surgical ward of a hospital.

Content: Research staff screened older adults who visited the emergency department for falls. If patients reported an unexplained fall (not caused by a slip or a trip or attributable to a medical cause) they were eligible for clinical assessment from the Cardiovascular Investigation Unit (CIU). The CIU screened the patients for other causes of falls such as medications and gait and balance issues. The CIU screened for cardioinhibitory CSH by massaging the carotid sinus while continually monitoring blood pressure and heart rate. Patients that screened positive for cardioinhibitory CSH received a rate response dual-chamber pacemaker.

Duration: The initial assessment took 60 minutes. The pacemaker surgery lasted two to three hours and patients stayed in the hospital overnight.

Delivered by: A surgeon delivered this intervention. A nurse or physician performed the initial screening.

Minimum Level of Training Needed: A physician experienced at performing a pacemaker surgery. Screening for cardioinhibitory CSH should be done by a health professional experienced at performing carotid sinus massage.


Available Materials: None at this time.

Study Citation: Kenny RA, Richardson DA, Steen N, Bexton RS, Shaw FE, Bond J. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). Journal of American College of Cardiology. 2001 Nov 1;38(5):1491–6.

84



Rose Kenny Cardiovascular Investigation Unit Royal Victoria Infirmary/MRC Development Centre for Clinical Brain Ageing Newcastle General Hospital Newcastle Upon Tyne, United Kingdom.


mailto:RKENNY%40tcd.ie?subject=

85


Study of 1000 Iu Vitamin D Daily for One Year Pfeifer, et al. (2009) This study evaluated the effectiveness of a one-year vitamin D and calcium supplementation program in reducing falls among older adults compared to a calcium only supplementation program. After one year, the intervention participants were 27 percent less likely to fall. After an additional eight months, participants were 39 percent less likely to fall compared to those who did not receive vitamin D.

Population: Participants were community-dwelling adults aged 70 or older with vitamin D (25[OH] D) serum levels below 78 nmol/l (nanomoles per liter)

Geographic Location: Bad Pyrmont, Germany

Focus: Investigate the effectiveness of long term vitamin D supplementation on falls.


Content: At the beginning of the study, a physician met with participants and collected medical history, height and weight, blood, and information on nutrition, physical activity, tobacco use, and alcohol use.

Participants were given a four month supply of 500 IU of vitamin D and 500 mg of calcium supplements and told to take the supplements twice daily at breakfast and dinner. Participants were told to avoid taking additional vitamin D and calcium supplements. The participants visited the clinic every four months to have their progress monitored and to receive additional supplements.

Duration: Participants took vitamin D and calcium supplements twice a day for one year and were monitored for an additional eight months. Participants attended five 1-hour clinical visits over the 20-month study period

Delivered by: This intervention was delivered by a physician.

Minimum Level of Training Needed: A nurse, with the supervision of a physician, could deliver this intervention. A physician needs to make the recommendation.

Key Elements:

• Physicians should discuss possible benefits and side effects with each patient.

• It may be beneficial to assess medical history and dietary habits.

• Measuring 25(OH) D serum levels in every patient is not necessary.

• A good personal relationship between the physician and patient increases compliance.


86


Study Citation: Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporosis International. 2009 Feb;20(2):315–22.

Supplemental ArticlePfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C. Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women. Journal of Clinical Endocrinology and Metabolism. 2001 Apr;86(4):1633–7.


M. Pfeifer Institute of Clinical Osteology “Gustav Pommer” Clinic “Der Fürstenhof”, Am Hylligen Born 7, 31812 Bad Pyrmont, Germany


mailto:iko_pyrmont%40t-online.de?subject=

87


Quality use of Medicines Program Pit, et al. (2007)This intervention focused on:

• Designing a convenient system for reviewing medicine within routine general practice visits

• Teaching physicians to conduct medication reviews with their older patients.

Certain medications increase the risk of falling. Participating physicians received instruction on geriatric prescribing and a financial incentive to review medications. The physicians recruited their patients to participate in the study. Participants completed the Medication Risk Assessment (MRA) form in the waiting room and showed this feedback to their physician. After 12 months, participants in the intervention group were 39 percent less likely to fall and 46 percent less likely to experience a fall-related injury than those whose physician’s did not receive the educational program.

Population: Participants were adults 65 or older who lived in the community and were recruited by their general practitioners (GPs) to participate in this study.

Geographic Location: Hunter Region, New South Wales, Australia

Focus: Educate GPs about the importance of reviewing medications with their older patients.

Program Setting: This intervention was conducted in the GP’s office.

Content: The intervention consisted of three parts: 1) education, 2) medication risk assessment, and 3) completion of a Medication Review Checklist (MRC).

A behavioral scientist conducted an initial 15-minute session and introduced the intervention to the physician and clinical staff. A clinical pharmacist who was experienced in conducting medication reviews visited each GP twice. The pharmacist also provided materials about prescribing for older adults, the MRC and the MRA for patients. The MRA contained a list of 31 risk factors for experiencing medication issues (e.g., taking more than four medications/day, medication side effects).

Patients completed the Medication Risk Assessment in the waiting room. The GP later reviewed the Assessment to determine if the patient would benefit from a medication review.

The Medication Review Checklist contained a list of potential problems and possible solutions. Problems included:

• Number of medications prescribed to patient

• Patient compliance in taking prescribed medications

• If the patient was prescribed specific drug categories (e.g., benzodiazepines, NSAIDS, over-the-counter medicines)

88


• If the patient had experienced any adverse drug reactions

• After reviewing the patient’s medications, the GP initiated appropriate prescribing changes.

An MRC was completed for each at-risk patient. Physicians received a monetary incentive after completing 10 MRCs.

Duration: The introductory session lasted 15 minutes. Each GP received two 1-hour educational sessions from the pharmacist. Office staff reported that it took on average 3.5 minutes per patient to hand out the risk assessments and to answer any questions. Medication reviews took place during regular office visits and lasted 15–20 minutes.

Delivered by: A behavioral scientist explained the intervention to the GP and office staff. A clinical pharmacist explained the medication-related issues. GPs conducted medication reviews.

Minimum Level of Training Needed: A pharmacist or physician with experience conducting medications reviews should lead the education sessions. A physician should conduct the medication reviews.

Key Elements:

• To maintain program fidelity the program should not be altered.

• An understanding of behaviour change theory.

Available Materials: The medication risk self-assessment for patients, and a medication review checklist are available in Appendix C-6.

Study Citation: Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman DA. A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Medical Journal of Australia. 2007 Jul 2;187(1):23–30.

Supplemental ArticlesPit SW. Improving quality use of medicines for older people in general practice. University of Newcastle (Australia); 2004. PhD thesis.

Pit, S., Byles, J. Older Australians’ medication use: self-report by phone showed good agreement and accuracy compared with home visit. Journal of clinical epidemiology. 2010 63:428–34.

Pit, S.W., Byles, J.E., Cockburn, J. Prevalence of self-reported risk factors for medication misadventure among older people in general practice. Journal of Evaluation in Clinical Practice. 2008 14(2), 203–208.

Pit, S.W., Byles, J.E. Accuracy of telephone self-report of drug use in older people and agreement with pharmaceutical claims data. Drugs and Aging. 2008 25(1), 7–80.

89


Pit, S.W., Byles, J.E., Henry, D.A., Holt, L., Hansen, V., Bowman, D. (2007) Quality Use of Medicines Program for general practitioners and older people: a cluster randomised controlled trial. Medical Journal of Australia. 2007 187(1), 23–30.

Pit, S.W., Byles, J.E., Cockburn, J. Medication review: patient selection and general practitioner’s report of medication-related problems and actions taken. Journal of the American Geriatrics Society. 2007 55(6), 927–934.


Dr. Sabrina Pit University Centre for Rural Health 61 Uralba Street Lismore | NSW 2480

Tel: +61 2 6620 7570| F + 61 2 6620 7270 | M 04 29 45 57 20 Email: [email protected]

mailto:sabrina.pit%40sydney.edu.au?subject=

90


Podiatry & Exercise Intervention Spink, et al. (2011)This study tested the effectiveness of a podiatry intervention coupled with exercise and education to prevent falls among older adults with disabling foot pain and an increased risk of falls.

• Disabling foot pain was defined as foot pain lasting for at least a day within the last month and a positive response of “some days” or “most/every days” to at least one item on the Manchester foot pain and disability index.

• Participants were considered at increased risk of falling if they had fallen in the previous 12 months, scored greater than one on the physiological profile assessment tool, or took >10 seconds on the alternate stepping test.

Intervention components included orthoses (custom molded shoe inserts), advice about and subsidies to pay for safe footwear, a foot and ankle exercise program, and fall prevention education. Overall, the fall rate for the intervention group was 36 percent lower than for the control group.

Population: Participants were adults aged 65 and older who lived in the community and were not cognitively impaired. All participants reported disabling foot pain and were at increased risk for falling. Over two-thirds of participants were female.

Geographic Location: Melbourne, Australia

Focus: A podiatry intervention to reduce fall risk among older adults with disabling foot pain.

Program Setting: A podiatrist fitted participants with customized shoe inserts and provided advice about safe footwear and fall prevention education at a health science clinic. The recommended exercises were performed at home.

Content:

Foot orthoses: The podiatrist issued participants shoe inserts (FormthoticsTM) that were heat molded to the participants’ foot shape and customized with 3mm of cushioning material to redistribute pressure away from any painful plantar lesions.

Footwear: The podiatrist also assessed participants’ outdoor footwear using a validated form. Inappropriate footwear included heels over 1¾”, narrow heels, no ankle support, and a fully worn or smooth sole.

For participants with inappropriate footwear, the podiatrist provided a handout with pictures that illustrated safe and unsafe shoes, information about retailers of orthopedic footwear, and a subsidy to use toward purchasing safer shoes.

91


Exercise: The exercise component consisted of a 30-minute foot and ankle exercise routine that participants performed at home three times a week for six months. Participants received an instruction booklet and DVD that detailed the exercises. These included:

• Calf and toe stretches (using a rubber band).

• Strength training for the ankles (heel raises and using a Theraband™) and toes (using an archxerciser).

• Range of motion exercises such as ankle circling.

• Participants were instructed to increase the number of repetitions and/or level of resistance as the study progressed, based on their ability.

Education: The podiatrist used the Australian government produced booklet entitled Don’t Fall for It, Falls can be Prevented, which outlines fall risk factors and prevention strategies.

Duration: Foot orthoses: Participants were instructed to wear their shoe inserts every day during the six months of the intervention period.

Exercise: 30 minutes three times a week for six months.

Education: Fall prevention education and information about appropriate footwear were provided during a single visit lasting 45–60 minutes. The podiatrist contacted participants at 1, 4, 12, and 20 weeks after their visit to provide encouragement, promote adherence, and to answer questions

Delivered by: A podiatrist with experience in older adult fall prevention delivered the general falls prevention education and instructions about safe footwear. He also fitted the participants with their shoe inserts and gave each participant a booklet and a DVD detailing the foot and ankle exercises.

Minimum Level of Training Needed: Podiatrist or other health professional with experience in delivering exercise programs and prescribing foot orthoses.

Key Elements: Foot and ankle exercises performed three times a week.


• “Podiatry and Fall Research Project: Project Booklet” that includes the safe shoe handout and foot and ankle exercise program*

*See Appendix C-7

92


Study Citation: Spink MJ, Menz HB, Fotoohabadi MR, Wee E, Landorf KB, Hill KD, et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial. British Medical Journal (Clinical research ed). 2011;342:d3411.

Supplemental Article Barton CJ, Bonanno D, Menz HB. Development and evaluation of a tool for the assessment of footwear characteristics. Journal of Foot Ankle Research. 2009 Apr 23;2:10.


Dr. Martin Spink Faculty of Health and Medicine University of Newcastle Building BE 10 Chittaway Road Ourimbah NSW 2258 Australia


mailto:Martin.Spink%40newcastle.edu.au?subject=

93



characteristics for the 10 Single Focused clinical interventions.

94


ble

1.

Su

mm

ary

Tab

le o

f S

tud

ies

and

Stu

dy

Po

pu

lati

on

Ch

arac

teri

stic

s

Stud

yN

o . S

tud

y Pa

rtic

ipan

tsM

ean

Age

%

Fem

ale

Rac

e/Et

hnic

ity

Soci

oeco

nom

ic S

tatu

s (S

ES)

Prev

ious

Fal

lsO

ther

C

hara

cter

isti

cs

Bisc

hoff

-Fer

rari

200

644

571

55%

97%

Whi

te

2.7

% B

lack

0.2%

Asi

an

NA*

NA

Cam

pbel

l 199

972

7578

%M

ost w

ere

Whi

teN

A44

%M

ean

num

ber

of

med

icat

ions

=6

Clem

son

2012

317

8355

%M

ost w

ere

whi

te46

% e

duca

tion

>H

S90

% h

ad fa

ll w

ith

inju

ry in

pas

t yea

r

Gal

lagh

er 2

004

245

7210

0%N

AN

A10

0%

Har

an 2

010

606

8065

%M

ost w

ere

Whi

teN

A37

% h

ad ≥

2 in

pa

st y

ear

Har

woo

d 20

0415

081

.210

0%M

ost w

ere

Whi

teN

A10

0%10

0% h

ad a

hip

fr

actu

re

Har

woo

d 20

0530

678

.510

0%M

ost w

ere

Whi

teN

AA

bou

t 50%

fell

in

past

yea

rM

ean

num

ber

of

med

icat

ions

=4

Kenn

y 20

0117

573

60%

NA

NA

100%

Pfei

fer 2

009

242

76.5

75%

100%

whi

te10

0%≥1

2 ye

ar o

f ed

ucat

ion

NA

Pit 2

007

849

olde

r ad

ults

; 20

Gen

eral

pr

acti

tion

ers

NA

59%

NA

for d

octo

rs;

Pati

ents

mos

tly

whi

te

NA

25%

Spin

k 20

1130

574

69%

67%

bor

n in

A

ustr

alia

75%

rece

ived

a s

tate

fu

nded

pen

sion

24%

had

pri

mar

y le

vel

educ

atio

n on

ly

56%

fell

in p

ast y

ear;

31%

>2

falls

in

past

yea

r

34%

live

d al

one

*No

info

rmat

ion

avai

labl

e

95


Tab

le 2

. S

tud

y M

eth

od

olo

gy

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Bisc

hoff

-Fer

rari

200

6Bo

ston

, Mas

sach

uset

tsPa

rtic

ipan

ts re

crui

ted

thro

ugh

mai

ling

lists

and

pr

esen

tati

ons

≥65

Use

of

bisp

hosp

hona

te,

calc

iton

in, e

stro

gen,

ta

mox

ifen

citr

ate,

or

test

oste

rone

(w/

in 6

mo)

or f

luor

ide

(w/i

n 2

yrs)

; hx

of

rena

l dis

ease

or

rena

l sto

ne(w

/in

5 yr

); cu

rren

t can

cer,

hyp

erpa

rath

yroi

dism

, di

etar

y ca

lciu

m

inta

ke >

150

0 m

g/d,

la

bor

ator

y ev

iden

ce o

f ki

dney

or l

iver

dis

ease

; or

bila

tera

l hip

sur

gery

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

sen

t a

pos

tcar

d af

ter e

very

fall.

Fa

lls a

lso

wer

e re

cord

ed

ever

y 6

mon

ths

duri

ng

clin

ical

vis

its.

3 ye

ars

Fall

risk

, ove

rall

ORf =

0.77

(0.5

1–1.

15)

Hyp

erca

lciu

ria,

co

nsti

pati

on,

epig

astr

ic

dist

ress

, sw

eati

ngFa

ll ri

sk, f

emal

eO

Rf =0.

54(0

.30–

0.97

)

Fall

risk

, mal

eO

Rf =0.

93 (0

.50–

1.72

)

Fall

risk

, les

s ac

tive

fem

ale

ORf =

0.35

(0.1

5–0.

81)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

96


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Dun

edin

, New

Ze

alan

dId

enti

fied

from

gen

eral

pr

acti

ce re

gist

ers

≥65

yea

rs o

ld; c

urre

ntly

ta

king

a b

enzo

diaz

epin

e,

othe

r hyp

noti

c,

anti

depr

essa

nt, o

r maj

or

tran

quill

izer

; am

bula

tory

in

own

hom

e; n

ot re

ceiv

ing

phys

ical

ther

apy;

phy

sici

an

thou

gh p

atie

nt w

ould

b

enef

it fr

om p

sych

otro

pic

med

icat

ion

wit

hdra

wal

Cogn

itiv

e im

pair

men

tYe

sN

o

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

cale

ndar

s44

wee

ksFa

ll Ra

teRR

b = 0

.34

(0.1

6–0.

73)

Non

e

Num

ber

of f

alle

rsRR

b = 0

.61

(0.3

2–1.

17)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Gal

lagh

er 2

004

Om

aha,

Neb

rask

aM

ailin

g lis

ts u

sed

to c

onta

ct

wom

en in

the

Om

aha,

N

ebra

ska

area

Age

65

to 7

7 ye

ars,

not

os

teop

orot

ic (f

emor

al n

eck

dens

ity

in n

orm

al ra

nge

Seve

re c

hron

ic

illne

ss, p

rim

ary

hyp

erpa

rath

yroi

dism

, ac

tive

rena

l sto

ne

dise

ase,

or u

se o

f th

iazi

de e

stro

gen,

flu

orid

e, d

iure

tics

, bi

spho

spho

nate

s or

an

tico

nvul

sant

s in

pa

st 6

mon

ths

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

In p

erso

n at

wee

k 6,

3

mon

ths

& th

en e

very

6

mon

ths

3 ye

ars

Num

ber

of f

alle

rsRR

d=

0.62

(0.5

4–0.

93)

Hyp

erca

lcae

mia

, hy

per

calc

iuri

a;

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

97


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Har

an 2

010

Sydn

ey a

nd ll

awar

ra

regi

ons

of N

ew S

outh

W

ales

, Aus

tral

ia

Recr

uite

d b

etw

een

May

20

05 a

nd J

une

2007

Com

mun

ity

dwel

ling;

age

≥8

0 or

age

≥65

& fe

ll in

pa

st 1

2 m

onth

s or

faile

d th

e TU

GT;

use

d m

ulti

foca

l le

nses

>3x

wee

k; h

ad

seen

an

opto

met

rist

or

opht

halm

olog

ist i

n pa

st

12 m

onth

s

Curr

ent u

se o

f sin

gle

lens

gla

sses

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

diar

y w

/ te

leph

one

follo

w u

p if

need

ed

13 m

onth

s af

ter

rand

omiz

atio

n (A

vera

ge

12 m

onth

s af

ter r

ecei

ving

gl

asse

s)

Fall

rate

(Ove

rall)

IR

Ra = 0

.92(

0.73

–1.1

6)

Fall

rela

ted

frac

ture

s in

b

oth

grou

ps.

Inte

rven

tion

gr

oup

exp

erie

nced

m

ore

non-

fall

rela

ted

inju

ries

. In

crea

sed

num

ber

of

out

door

falls

in

inte

rven

tion

m

emb

ers

who

w

ere

less

act

ive

Fall

rate

(Hig

h ou

tsid

e ac

tivi

ty)

IRRa =

0.60

(0.4

2–0.

87)

Fall

rate

(Low

out

side

ac

tivi

ty)

IRRa =1

.29

(0.9

5–1.

75)

Fall

rate

(Out

side

falls

, ov

eral

l)IR

Ra =1.0

0 (0

.78–

1.28

)

Fall

rate

(Out

side

falls

-Hig

h ou

tsid

e ac

tivi

ty)

IRRa =

0.61

(0.4

2–0.

87)

Fall

rate

(Out

side

falls

-Low

ou

tsid

e ac

tivi

ty)

IRRa =1

.56

(1.1

1–2.

19)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Har

woo

d 20

04N

otti

ngha

m, U

nite

d Ki

ngdo

mW

omen

adm

itte

d to

or

thog

eria

tric

reha

b w

ard

w/i

n 7

days

of s

urge

ry fo

r hi

p fr

actu

re

Rece

nt s

urge

ry fo

r hi

p fr

actu

re, p

revi

ous

com

mun

ity

resi

denc

e,

prev

ious

ly in

dep

ende

nt in

ac

tivi

ties

of d

aily

life

Prev

ious

ly

inst

itut

iona

lized

, di

seas

e or

med

icat

ion

know

n to

aff

ect b

one

met

abol

ism

, < 7

on

10-p

oint

men

tal

stat

us te

st

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

In p

erso

n in

terv

iew

s at

3,

6, a

nd 1

2 m

onth

s12

mon

ths

Num

ber

of f

alle

rsRR

d=

0.48

(0.2

6–0.

90)

Non

e re

por

ted

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

98


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Har

woo

d 20

05N

otti

ngha

m, U

nite

d Ki

ngdo

mPa

rtic

ipan

ts re

ferr

ed to

pr

ogra

m b

y op

tom

etri

stA

ged

> 7

0 ye

ars

w/ c

atar

act

& n

o pr

evio

us o

cula

r su

rger

y

Cat

arac

t not

sui

tabl

e fo

r sur

gery

by

phac

oem

ulsi

ficat

ion,

se

vere

refr

acti

on e

rror

in

2nd

eye

, vis

ual

fiel

d de

ficit

s, s

ever

e co

-mor

bid

eye

dise

ase

affe

ctin

g vi

sual

acu

ity,

re

gist

ered

par

tial

ly

sigh

ted

as a

resu

lt o

f ca

tara

ct, o

r mem

ory

prob

lem

s

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

diar

y w

/ te

leph

one

or in

per

son

inte

rvie

ws

12 m

onth

sFa

ll ra

teRR

b=

0.66

(0.4

5–0.

95)

Non

e re

por

ted

Num

ber

of f

alle

rsRR

d=

0.95

(0.6

8–1.

33)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Kenn

y 20

01N

ewca

stle

Up

on T

yne,

U

nite

d Ki

ngdo

mO

lder

adu

lts

who

wer

e

seen

in a

n em

erge

ncy

ro

om b

ecau

se o

f an

unex

plai

ned

fall

Age

≥50

w/ c

ardi

o-in

hibi

tory

car

otid

sin

us

synd

rom

e w

ho w

ere

seen

in

an

ER b

ecau

se o

f an

unex

plai

ned

fall

Cogn

itiv

e im

pair

men

t, m

edic

al e

xpla

nati

on

for f

all,

blin

d,

docu

men

ted

acci

dent

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103

Multifaceted Interventions

MulTIFACETED INTErVENTIONS

Stepping On Clemson, et al (2004) 104

PROFET (Prevention of Falls in the Elderly Trial) Close, et al (1999) 107

Accident & Emergency Fallers Davison, et al (2005) 109

The NoFalls Intervention Day, et al (2002) 112

The SAFE Health Behavior and Exercise Intervention Hornbrook, et al (1994) 115

Falls Team Prevention Program Logan, et al (2010) 118

KAAOS (Falls and Osteoporosis Clinic) Palvanen, et al (2014) 120

Multifactorial Fall Prevention Program Salminen, et al (2009) 124

Nijmegen Falls Prevention Program (NFPP) for adults with Osteoporosis Smulders, et al (2010) 127

The Winchester Falls Project Spice, et al (2009) 130

Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) Tinetti, et al (1994) 133

A Multifactorial Program Wagner, et al (1994) 136

Table 1 Summary Table of Studies and Study Population Characteristics 139



104


Stepping On Clemson, et al. (2004) This study used a series of small group sessions to teach fall prevention strategies to community-dwelling older adults. The fall rate among participants was reduced about 30 percent compared with those who did not receive the intervention. The intervention was especially effective for men. The fall rate among male participants was reduced almost two-thirds.


Population: Participants were individuals who had fallen in the previous year or who were concerned about falling. All were 70 or older and lived in the community. Most study participants were female.


Focus: Improve self-efficacy, empower participants to make better decisions and learn about fall prevention techniques, and make behavioral changes.

Program Setting: Initial sessions were conducted in easily accessible community settings. Refreshments were provided before and after the sessions to give participants an opportunity to talk to each other and with the facilitators and content experts. Follow-up visits took place in the participants’ homes.

Content: The program addressed multiple fall risk factors: improving lower limb balance and strength, improving environmental and behavioral safety in both the home and community, and encouraging visual and medical screenings to check for low vision and possible medication problems.

Each session covered a different aspect to reducing fall risk:

• Session one: Risk appraisal; introducing balance and strength exercises

• Session two: Review and practice exercises; how to move safely in the home

• Session three: Hazards in and around the home and how to remove or reduce them

• Session four: How to move safely in the community; safe footwear and clothing

• Session five: Poor vision and fall risk; the benefits of vitamin D, calcium, and hip protectors

• Session six: Medication management; review of exercises; more strategies for moving safely in the community

• Session seven: Review of topics covered in program

• Follow-up home visit: Review fall prevention strategies; assist with home adaptations and modifications, if needed

• Three-month booster session: Review achievements and how to maintain motivation

105


Duration:

• Seven weekly two-hour program sessions

• A 1–1½-hour home visit, six weeks after the final session

• A 1-hour booster session three months after the final session

Delivered by: An occupational therapist (OT) facilitated the program and conducted the home visits.

A team of content experts, trained by the OT and guided by the Stepping On manual, led the sessions. These included:

• A physical therapist (PT) who introduced the exercises and led a segment on moving about safely.

• An OT who led segments on home safety, community safety, behavioral methods to sleeping better, and hip protectors.

• An older adult volunteer from the Roads and Traffic Authority who spoke on pedestrian safety.

• A retired volunteer nurse from the Medicine Information Project who discussed how to manage medications.

• A mobility officer from the Guide Dogs who spoke on coping with low vision (The Stepping On manual has a topics section that outlines the information required to run this session).

Minimum Level of Training Needed: The program should be facilitated by a health professional with experience both in group work and in working with older adults in community settings.

This program requires a PT, an OT, a person trained in road safety for older drivers who can discuss pedestrian safety, a low vision expert, and a nurse or community pharmacist who can discuss medications. Other potentially useful content experts include a podiatrist or perhaps a nutritionist. All content experts need to receive training in fall prevention.

Key Elements: Using content experts is critical. It is also important to let each expert know what is expected of them, to provide feedback, and to make sure each focuses on fall prevention.

The Stepping On manual is essential for all program facilitators and provides a step-by-step guide to running the seven-week group program. It outlines topic areas and provides the background information for each content expert.

Chapters Include:

• Essential background information for understanding the conceptual underpinning of the program and the group process

• Valuable content information for all the key fall prevention areas that can be used to train local experts participating in the program

106


• A guide to useful resources

• Handouts for group participants

• Ideas on recruitment and evaluation

Available Materials: The program manual Stepping On: Building Confidence and Reducing Falls. A Community-Based Program for Older People by Dr. Lindy Clemson is available at Freiberg Press Inc. PO Box 612 Cedar Falls, IA 50613, United States E-mail: [email protected]

Study Citation: Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Geriatrics Society. 2004 Sep;52(9):1487–94.


Lindy Clemson, PhD Associate Professor in Ageing, Head of Discipline (Occupational Therapy) Faculty of Health Sciences, The University of Sydney Cumberland Campus PO Box 170 Lidcombe 1825, Australia



In 2011, CDC funded the translation of Stepping On Program for dissemination and implementation in the U.S.


Betsy Abramson Deputy Director Wisconsin Institute for Healthy Aging

Office: 608-243-5691 E-mail: [email protected]

mailto:bfreiberg%40cfu.net?subject=

mailto:lindy.clemson%40sydney.edu.au?subject=

mailto:info%40wihealthyaging.org?subject=

107


PrOFET (Prevention of Falls in the Elderly Trial)� Close, et al. (1999) This study provided medical assessments for fall risk factors with referrals to relevant services and an occupational therapy home hazard assessment with recommendations for home modifications. After 12 months, those in the intervention group were 60 percent less likely to fall once and 67 percent less likely to fall repeatedly (at least three times), compared with those who did not receive the intervention.

Population: Participants were seniors who had been treated for a fall in a hospital emergency department. All were aged 65 or older and lived in the community. Two-thirds of participants were female.

Geographic Locale: London, United Kingdom

Focus: Identify medical risk factors and home hazards, and provide referrals and/or recommendations to reduce fall risk and improve home safety.

Program Setting: The medical assessment took place in an outpatient hospital clinic. The occupational therapy assessment took place in participants’ homes.

Content: The medical assessment was conducted soon after the fall that was treated in the emergency room. It included assessments of visual acuity, postural hypotension, balance, cognition, depression, and medication problems. The results were used to identify and address problems that could contribute to fall risk. Participants received referrals to relevant services, as appropriate, based on identified risk factors.

The home assessment was conducted during a single visit. The occupational therapist (OT) identified environmental hazards in the home such as uneven outdoor surfaces, loose rugs, and unsuitable footwear. Based on findings, the OT provided advice and education regarding safety within the home, made safety modifications to the home with the participant’s consent, and provided minor safety equipment.

The OT made social service referrals for participants who required hand rails, other technical aids, adaptive devices such as grab bars and raised toilet seats, and additional support services.

Duration: The average length of the medical assessment was 45 minutes. The average length of the home assessment was 60 minutes.

Delivered by: A physician specializing in geriatrics conducted the medical assessment. An OT delivered the home hazard assessment.

108


Minimum Level of Training Needed: This program could be implemented by:

• Appropriately trained geriatricians

• General practitioners with a strong interest in older adult health

• Trained physical therapists or nurses with the support of a general practitioner in case medication modification, referrals to specialists, or other medical services were required

Key Elements: For medication review and modification, a medical specialist rather than a general practitioner is recommended.


• Folstein mini-mental state examination (see Supplemental Articles)

• Modified Geriatric Depression Scale (see Supplemental Articles)

• Snellen vision assessment chart

• Medical assessment form*—the form used in the outpatient hospital clinic setting

• Accident and emergency assessment tool*—the instrument used in the emergency department to identify people at high risk of falling and those who should be referred for a comprehensive geriatric assessment

• Environmental hazards checklist*—the checklist used to guide the home assessment

* See Appendix C-8.

Study Citation: Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of Falls in the Elderly Trial (PROFET): A randomised controlled trial. Lancet.1999 Jan 9;353(9147):93–7.

Supplemental Articles Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975 Nov;12(3):189–98.

Sheikh J, Yesavage J. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontology. 1986;5(1/2):165–72.


Jacqueline Close, MD Neuroscience Research Australia Barker Street, Randwick Sydney NSW 2031, Australia


mailto:j.close%40neura.edu.au?subject=

109


Accident & Emergency Fallers Davison, et al. (2005)This multifaceted intervention was designed for people who fell repeatedly. Participants received a medical fall risk assessment by a geriatrician at the hospital and had in-home assessments by physical therapists (PTs) and occupational therapists (OTs). Each participant received an individualized intervention designed to reduce their fall risk factors.

After 12 months, the fall rate in the intervention group was 36 percent lower than the rate in the comparison group.

Population: Participants were men and women aged 65 or older. All had experienced at least one fall in the past year and also had been treated in the emergency department for another fall or fall injury. About three-quarters of participants were female.

Geographic Locale: Newcastle, United Kingdom

Focus: Identify and modify each participant’s fall risk factors.

Program Setting: The medical assessment was conducted in a hospital and the physical therapy and home assessments were conducted in participants’ homes.

Content: After taking a medical and fall history, a physician conducted a full clinical examination that included vision, medication review, a neurological examination, and a cardiovascular assessment. Postural blood pressure was assessed and laboratory tests and an electrocardiogram were performed.

Interventions for identified fall risk factors followed recognized treatment recommendations. Each participant was referred to relevant specialists as needed, such as to an optometrist for vision correction or cataract removal; given advice or medication to reduce orthostatic hypotension; and had medications associated with falls stopped, reduced, or modified.

The PT evaluated each participant’s gait and balance and, if necessary, provided gait re-education and the functional training program used in the Yale FICSIT (Frailty and Injuries: Co-operative Studies of Intervention Studies) study (See Koch, et al. and Tinetti, et al. under Supplemental Articles). The main intervention was exercise to strengthen the proximal leg muscles and ankle dorsiflexion muscles. If needed, participants were given assistive devices, had their footwear modified or replaced, and were referred to a podiatrist.

An OT used a room-by-room environmental fall hazard checklist, the User Safety and Environmental Risks (USER) checklist, to identify potential hazards throughout the home including the kitchen, bathroom, bedroom, and stairs (See Hagedorn, et al. under Supplemental Articles). Specific areas included the position and condition of furniture, cabinets and shelving heights, loose rugs and tripping hazards, grab bars and handrails, toilet height, and lighting (including the use of night lights).

110


Environmental interventions followed published criteria (See Tideiksaar under Supplemental Articles) and included advice about reducing home hazards as well as suggestions for specific home modifications.

Duration: On average, participants visited the hospital twice for the medical intervention. The initial hospital assessment took one hour and the medical intervention visit was 20 minutes. Participants received two physical therapy intervention visits; the initial physical therapy assessment took 45 minutes and the intervention lasted 15 minutes. The occupational therapy visit took 45 minutes and the follow-up visit about one month later lasted 20 minutes.

Delivered by: A physician performed the medical assessments and made appropriate referrals to specialists; a PT conducted the gait and balance assessment and re-education; and an OT conducted the home hazard assessment and recommended home modifications.

Minimum Level of Training Needed: This intervention requires a variety of highly trained health care professionals. Complex individualized interventions of this type cannot be implemented by individuals with lower levels of training.

Key Elements: Multifactorial assessments and interventions conducted by highly trained individuals in each of the three disciplines.

Available Materials: No additional materials are available.

Study Citation: Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending accident and emergency benefit from multifactorial intervention: A randomised controlled trial. Age and Ageing. 2005 Mar;34(2):162–8.

Supplemental Articles Koch M, Gottschalk M, Baker DI, Palumbo S, Tinetti ME. An impairment and disability assessment and treatment protocol for community-living elderly persons. Physical Therapy. 1994 Apr;74(4):286–94. Multifaceted Interventions

Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett, P, Gottschalk M, Koch ML, Trainor K, Horwitz RI. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine. 1994 Sept 29;331(13):821–7.

Hagedorn R, McLafferty S, Russell D. The User Safety and Environmental Risk Checklist (USER). In: Anonymous falls: Screening and risk assessment for older people in the community. Worthing Priority Care NHS Trust. 1998:48–57.

Tideiksaar R. Preventing falls: Home hazard checklists to help older patients protect themselves. Geriatrics. 1986 May;41(5):26–8. Multifaceted Interventions

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Dr. John Davison Falls and Syncope Service Newcastle upon Tyne Hospitals NHS Trust Royal Victoria Infirmary Newcastle upon Tyne NEI 4LP, United Kingdom

Fax: (+44) 191 222 5638 E-mail: [email protected]

mailto:john.davison%40ncl.ac.uk?subject=

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The NoFalls Intervention Day, et al. (2002)This study looked at the effectiveness of group-based exercise in preventing falls when used alone or in combination with vision improvement and/or home hazard reduction. The intervention components focused on increasing strength and balance, improving poor vision, and reducing home hazards.

The group-based exercise was the most potent single intervention; when used alone, it reduced the fall rate by 20 percent. Falls were reduced further when vision improvement or home hazard reduction was combined with exercise. The most effective combination was the group-based exercise with both vision improvement and home hazard reduction. Participants who received all three components were one-third less likely to fall.

Population: All participants were aged 70 or older and lived in the community. Sixty percent were female.

Geographic Locale: City of Whitehorse, Melbourne, Australia

Focus: Increase strength and balance, improve poor vision, and reduce home hazards.

Program Setting: The exercise program was delivered in community settings such as exercise rooms in fitness centers and community health centers. The vision intervention was delivered via usual services available in the community. Participants went to their optometrist or ophthalmologist if they had one. If any further action was required, it was facilitated using normal services such as hospitals for cataract surgery, optometrists for new glasses, and general practitioners or ophthalmologists for medication if required. The home hazard intervention was conducted in participants’ homes.

Content: Exercise: The exercise intervention consisted of weekly one-hour classes plus daily home exercises. Classes were designed by a physical therapist (PT) to improve flexibility, leg strength, and balance. About one-third of the exercises were devoted to balance improvement. Exercises were adjusted for participants with limitations. Music was played during the sessions.

Leaders provided a social time with coffee and tea after each session to talk informally about exercise improvements and opportunities.

Vision improvement: The vision intervention included referral to an appropriate eye care provider if a participant’s vision fell below predetermined criteria during the baseline assessments for visual acuity, contrast sensitivity, depth perception, and field of view. Criteria for referral included more than four lines difference between the line of smallest letters read correctly on the high and low contrast sections of the vision chart or any loss of field of view.

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A referral was recommended if:

(1) A potential visual deficit was identified and the participant was not already receiving treatment, or

(2) If a deficit had been identified previously but the participant had not received treatment during the previous 12 months. The intervention consisted of the participant receiving the recommended treatment by an appropriate specialist.

Home hazard reduction: The home hazard assessment consisted of a walk-through using a checklist for those rooms used in a normal week. The checklist included a comprehensive section defining the different areas of the house and specific hazards. The checklist was divided into rooms or areas of the house—access points (main entry door, back door, etc.), hallways, stairwells, dining room, living room, den, bedrooms, and wet areas (kitchen, bathroom, laundry rooms). Within each of these areas, the focus was on steps and stairs, floor surfaces, lighting, and some key furniture items or fixtures such as a favorite chair or bathroom fixtures.

After the assessment, the results were discussed with the participant and potential interventions described in the checklist were suggested. If the participant agreed to the intervention, it was determined who would carry it out. Hazards could be removed or modified by the participant, their family, the City of Whitehorse home maintenance program, or some other person. Study staff visited the participants’ homes and provided quotes for the materials needed for the suggested modifications; labor was provided free of charge.

Duration: Exercise: Weekly one-hour group classes for 15 weeks and 25 minutes of daily home exercises.

Vision improvement: Duration depended on the specific intervention (such as cataract surgery or new glasses).

Home hazard reduction: Duration depended on the length of time the home modifications were left in place by the participant.

Delivered by: Exercise: Classes were led by trainers who were accredited to lead exercise classes for older adults, and were trained in the NoFalls program by the PT who designed the program.

Vision improvement: Initial assessment was conducted by nurses with up to a half-day training required on the vision assessment. Detailed vision assessment was conducted by each participant’s usual eye care provider, general practitioner, local optometrist, or ophthalmologist.

Home hazard reduction: Home assessments were conducted by research nurses who followed the study protocol for assessment with one-day of training required on the home hazard assessment. Modifications were undertaken by participants, their family or a private contractor, or by the City of Whitehorse home maintenance program.

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Minimum Level of Training Needed: Exercise: Requires a basic level of exercise leadership training such as that received by a PT or certified fitness instructor.

Vision and home hazard assessments: Nurses or other allied health professionals with the appropriate training.

Key Elements: Although the most effective single component was the NoFalls exercise program, the complete program should be followed because partial implementation may not reduce falls.

Available Materials: The NoFalls exercise program manual, which was developed for trained professionals, is available free of charge in electronic format at www.monash.edu.au/muarc/projects/nofalls/.

These researchers have not made the home assessment protocol available because this intervention component by itself was not effective.

Study Citation: Day L, Fildes B, Gordon I, Fitzharris M, Flamer M, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. British Medical Journal. 2002 Jul 20;325(7356):128–33.


Professor Lesley Day PhD, MPH Monash Injury Research Institute Building 70 Monash University Wellington Road Clayton Victoria 3800 Australia


mailto:lesley.day%40monash.edu?subject=

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The SAFE Health behavior and Exercise Intervention Hornbrook, et al. (1994) The Study of Accidental Falls in the Elderly (SAFE) health behavior intervention was a program of four group classes on how to prevent falls. The classes addressed environmental, behavioral, and physical risk factors and included exercise with instructions and supervised practice. The home safety portion included a home inspection with guidance and assistance in reducing fall hazards.

Overall, participants were 15 percent less likely to fall compared with those who did not receive the intervention. Male participants showed the greatest benefit.

Population: All were participants were 65 or older and lived in the community. About 60 percent of participants were female.

Geographic Locale: Portland, Oregon, and Vancouver, Washington, United States

Focus: Reduce risky behaviors, improve physical fitness through exercise, and reduce fall hazards in the home.

Program Setting: No information was available on where risk education and group exercise classes took place. Home safety inspections were conducted in participants’ homes.

Content: The SAFE health behavior intervention consisted of four 1½-hour group classes that used a comprehensive approach to reducing fall risks. Classes addressed environmental, behavioral, and physical risk factors.

Classes included:

• A slide presentation on common household risks

• Discussions of behavioral risks such as walking on ice or using a chair to reach high places

• A self-appraisal of home hazards using a specially designed form

• Small group sessions during which participants worked together to develop action plans

Each class session also had an exercise component that included a brief demonstration of fall prevention exercises and about 20 minutes of supervised practice. Participants received a manual describing the exercises and were encouraged to begin walking at least three times a week.

The exercises were chosen to:

• Actively involve all parts of the body

• Maintain full range of motion of all joints

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• Strengthen muscles

• Improve posture

• Improve balance

During the home safety inspection, the assessor inspected the participant’s home and identified fall hazards using a standard protocol. The assessor encouraged the participant to remove or repair the hazards identified during this initial visit. The participant was also given fact sheets on how to obtain technical and financial assistance for making repairs and modifications to his or her home.

After the four classes were completed, the assessor returned to the participant’s home to check on the progress of repairs and to offer financial and technical assistance if needed, as well as discounts on safety equipment.

Duration:

• Two home visits, each lasting about 15 minutes

• Four weekly 1½-hour classes (including 20 minutes of supervised exercise) over a one-month period

Delivered by:

• The home inspection was performed by a BA-level home assessor who was trained during a two-day program that included practice assessments of elderly volunteers’ homes.

• The fall prevention program and exercise sessions were delivered by MA-level lifestyle change experts with various backgrounds including health behavior change and sports training. Each group meeting was conducted by a team consisting of a lifestyle change expert and a physical therapist.



Available Materials: No intervention materials were available for distribution at the time of publication. Please contact the principal investigator for information on how to obtain the exercise manual.

Study Citation: Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: Results from a randomized trial. The Gerontologist. 1994 Feb;34(1):16–23.

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Mark C. Hornbrook, PhD Chief Scientist The Center for Health Research, NW/HI/SE Kaiser Permanente Northwest 3800 North Interstate Avenue Portland, OR 97227-1110, United States


mailto:mark.c.hornbrook%40kpchr.org?subject=

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Falls Team Prevention Program Logan, et al. (2010)This study examined the effectiveness of a team-based, individually tailored intervention designed to reduce falls among older adults. The multifaceted intervention included group education, group and home-based strength and balance exercises, medication review, blood pressure screening, and home hazard assessments and modifications. After 12 months, the fall rate was 55 percent lower among people who took part in the program compared to those who did not.

Population: Participants were adults aged 60 or older who lived in the community (95 percent) or nursing homes (5 percent), and had called emergency services for an ambulance because of a fall, but were not taken to a hospital.

Geographic Location: Nottinghamshire, United Kingdom

Focus: Increase strength and balance, identify inappropriate medications, and reduce home hazards.

Program Setting: Programs were conducted primarily in patients’ homes. Optional group sessions were offered at community centers.

Content: The falls team was composed of an occupational therapist (OT), physical therapist (PT), and a nurse. The team provided participants with as many home sessions as they deemed clinically necessary.

• The OT and PT led optional group sessions twice a week for six weeks. These included group exercises and fall prevention education (e.g., reducing home hazards, information about safe footwear).

• A nurse reviewed participants’ medications and assessed their blood pressure.

• The PT taught the strength and balance exercises to participants in their homes. The PT used exercises from the Postural Stability program that was based on the FaMe and Otago Exercise programs. (See pages 8 and 30)

• The OT conducted the home hazard assessments and suggested modifications. The OT provided equipment (e.g., grab bars), advice (e.g., improved lighting), and taught participants how to get up from a fall.

• Referrals (e.g., family physician for follow-up, social services for home care) were made if needed.

Duration:

• Group sessions lasted two hours. These were held twice a week for six weeks on an ongoing basis. The first hour was devoted to strength and balance exercises and the second hour to fall prevention education.

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• Strength and balance sessions in the home lasted one-hour and were conducted once a week for a minimum of six weeks. However, sessions were continued for as long as the PT deemed necessary.

• Conducting the home hazard assessments and modifications took an hour, with subsequent follow-up if needed.

• Reviewing medications and screening blood pressure lasted about 30 minutes.

Delivered by: The intervention was delivered by a team composed of an OT, a PT, and a nurse.

Minimum Level of Training Needed: This intervention requires a variety of highly trained health care professionals. A PT who has experience with the Postural Stability program should deliver strength and balance exercises. An OT should conduct the home hazard assessments and modification recommendations. A nurse should complete the medication review.

Key Elements: Qualified health care professionals should continually assess the participants over the length of the program. The duration and the intensity should be modified as needed based on these ongoing assessments.

Available Materials: The educational materials were modified from the Guide to Action to Prevent Falls, available at: http://eprints.nottingham.ac.uk/1414.

Information about the accredited Postural Stability Instructor course in the United Kingdom is available at: http://www.laterlifetraining.co.uk.

Study Citation: Logan PA, Coupland CA, Gladman JR, Sahota O, Stoner-Hobbs V, Robertson K, et al. Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. British Medical Journal (Clinical research ed). 2010;340:c2102.


Pip Logan, PhD, MPhil HPHC Occupational Therapist Professor of Rehabilitation Research Deputy Head of Division B108a, B Floor Division of Rehabilitation and Ageing School of Medicine University of Nottingham NG7 2UH

Tel: 0115 8230235 Fax: 0788 4318920 Email: [email protected]

http://eprints.nottingham.ac.uk/1414

http://www.laterlifetraining.co.uk

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KAAOS (Falls and Osteoporosis Clinic)� Palvanen, et al. (2014)This study evaluated the effectiveness of a multidisciplinary falls risk assessment [assessment (by a doctor, nurse, and physical therapist [PT]) followed by appropriate interventions and follow-up if necessary. After one year, participants were 28 percent less likely to fall and 26 percent less likely to have an injurious fall compared to those who did not participant in the intervention.

Population: Participants were community-dwelling adults aged 70 and older with an increased risk of falling or fall induced injury.

• Participants were considered at increased risk of falling or fall induced injury if they had self-reported mobility issues, or more than two falls in previous 12 months, or a previous fracture, or history of hip fracture in a close relative, or confirmed or suspected osteoporosis, or a BMI <19, or illness that increases the risk of osteoporosis, falls, and fractures.

Geographic Location: Tampere and Lappeenranta, Finland

Focus: Identify and modify risk factors for falls at a center-based falls clinic

Program Setting: The intervention occurred at two falls clinics situated within health care centers.

Content: During the initial visit, the intervention team conducted a 3 hour assessment of fall risk factors for each participant.

• A nurse

– collected basic information and body measurements,

– assessed cognitive function, and

– measured blood pressure including postural blood pressure.

• A PT

– tested physical function using the Short Physical Performance Battery and the Timed Up and Go-test.

• A physician

– conducted a thorough medical examination including a review of medications.

• A PT or nurse

– conducted a 1-hour home hazard assessment on a separate day.

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Risk Factor Intervention

Assessed by physician:

General medical history and examination Referred to primary care physician

MedicationsRecommended reduction of drugs known to increase risk of falling. Withdrawal of redundant psychotropic medications

Visual impairment Referral to optician or ophthalmologist for glasses if necessary. Referral to ophthalmologist for cataracts

Assessed by a PT:

Low mobility

Referral to home or group strength and balance program if needed. The home training session lasted 45 minutes two to three times a week. Group classes were led by an exercise instructors experienced at teaching older adults and were 45 minutes once per week. Exercises were strength and balance focused and included half-squats, heel walking, and tandem-walking. Hip protectors, mobility assistive devices, and anti-slip shoe devices were recommended if deemed necessary

Low physical activity Prescription for increased physical activity according to functional ability

Assessed by a nurse:

Nutrition

Vitamin D and calcium supplementation recommended if dietary intake assessed as inadequate (>1000–1500 mg Calcium/day, >600–800 IU vitamin D/day). The physician wrote a prescription if necessary

Alcohol and smoking Reduction of alcohol advised. Cessation of smoking recommended

Assessed by a PT or nurse:

Home hazardsIn-home visit; recommend grab bars, mats for slippery floors; assessed lighting, security lights, smoke alarms and fire extinguishers, placement of wires and cords

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A nurse made a telephone call twice (after three months and again after nine months) to check adherence to the prescribed interventions and to provide further recommendations as needed. The participant visited the falls clinic at 6 months and 12 months after the initial intervention to receive a booster assessment from the doctor, nurse, and PT. The PT revaluated mobility, emphasized increasing physical activity, and measured adherence to at-home or group balance and training exercises. The nurse and doctor measured adherence to their previous recommendations and provided additional guidance if needed. The visit lasted 2¼ hours.

Duration:

• Three-hour fall risk assessment (one-hour each with the physician, nurse, and PT)

• One-hour home hazard assessment

• 45 minutes of home balance and strength training two to three times per week if necessary

• 45 minutes of group balance and strength exercise once per week if necessary

• Two short telephone calls three and nine months after the initial assessment

• Two, 2¼ hour follow-up visits (45 minutes each with physician, nurse, and PT) at six and twelve months after the initial assessment

Delivered by: Assessment and individualized interventions were conducted by physicians, nurses, and physical therapists.

Minimum Level of Training Needed: This intervention requires a variety of trained health care professionals including a physician, nurse, and PT. Preparation for conducting the baseline assessments requires a half-day training session.

Key Elements:

• Measuring functional ability and recommending strength and balance training

• Performing a medication review and eliminating/reducing medications that increase falls

• Assessing nutrition and prescribing supplementation if necessary

• Assessing home hazards and providing modifications and referrals

• Medical referrals, hip protectors and assistive devices, if indicated.

Available Materials: The structured home exercise handout and home hazard assessment checklist are available in Finnish.

Study Citation: Palvanen M, et al. Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 2014;45(1):265–71

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Contact Practitioners interested in using this intervention may contact the co-investigator for more information:

Professor Pekka Kannus, MD, PhD UKK Institute for Health Promotion Research P.O. Box 30 Fin-33501 Tampere Finland

Tel: +358-3-2829-336 E-mail: [email protected]

mailto:Pekka.Kannus%40uta.fi?subject=

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Multifactorial Fall Prevention Program Salminen, et al. (2009) This multifaceted fall intervention consisted of a geriatric fall risk assessment with counseling and guidance in fall prevention; home hazards assessment and modification; group and home-based exercise; group lectures on topics related to fall prevention; and monthly participation in a psychosocial group.

The intervention did not reduce falls overall. However, falls were decreased 41 percent in participants who had experienced three or more falls in the previous year and 50 percent in participants with more symptoms of depression.

Population: Participants were seniors aged 65 or older who lived in the community or in housing that provided occasional assistance, had no or little cognitive impairment, and had experienced at least one fall in the past year. Eighty-four percent of participants were female.

Geographic Locale: Pori, Finland

Focus: Assess and address each participant’s specific fall risk factors, improve physical fitness, provide information and counseling on fall prevention, assess and modify home hazards, and provide psychological support.

Program Setting: The fall risk assessment, counseling, and group exercise classes were conducted in the Pori Health Center or at home for those participants living in assisted housing. Lectures and psychosocial groups were held in a senior center. The home-based exercises and home assessment were carried out in participants’ homes.

Content: A geriatrician assessed each participant for medical factors that could increase their risk of falling such as disorders affecting balance and gait, the use of psychoactive medications, depression, and poor eyesight. If needed, referrals were made to an ophthalmologist for vision correction and to the primary care physician for follow-up on recommended medication changes. All participants who were not already taking calcium and vitamin D supplements were prescribed 500 mg calcium and 400 IU of vitamin D per day.

A public health nurse provided oral and written information about reducing personal fall risk factors as well as facts about safe environments, healthy diets, calcium and vitamin D supplements, and the use of hip protectors.

Trained nursing students conducted home hazard assessments using a detailed form. Participants were given oral and written instructions for safety modifications. A follow-up of the home modifications was made one year later.

A physical therapist (PT) led a group exercise class every two weeks. This included:

• 5 minutes of warm-up

• 15 minutes of balance, coordination, and weight-shifting exercises. Each exercise was performed for 45 seconds followed by 30 seconds of rest.

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• 20 minutes of circuit training for muscle strength. Two to four circuits were performed with three to five minutes of rest between circuits.

• 5 to 10 minutes of cool-down

The intensity of the exercises was increased progressively over time, based on the PT’s judgment of each person’s fitness level.

Participants also performed similar exercises at home three times a week. Participants received written information on performing home exercises based on the PT’s judgment of their physical condition.

Once a month, a lecture was given by a health professional on various topics including causes of falling, fall prevention, medications that can increase fall risk, nutrition, exercise, and home hazards.

Also once a month, participants attended a psychosocial group that provided recreational activities (e.g., discussing various topics such as news headlines, a musical performance, memory disorders, or exercise; reading poetry) and psychological support.

Duration:

• 45-minute fall risk assessment

• 45-minute home hazard assessment

• 45-minute information and counseling session

• 45- to 50-minute group exercise class once every two weeks plus 25 minutes of exercise at home three times per week

• One-hour health lecture once a month

• One-hour psychosocial group session once a month

Delivered by: A geriatrician conducted the fall risk assessment; a trained public health nurse provided information and counseling on fall prevention; trained nursing students conducted the home hazards assessment and psychosocial group sessions; a PT facilitated the group exercise sessions; and various health professionals (e.g., geriatricians, public health nurses, PTs, dieticians, podiatrists) gave lectures on topics related to falling.

Minimum Level of Training Needed: Risk assessments can be conducted by a trained nurse with referrals, if needed, to a general practitioner who specializes in geriatrics. Exercise groups can be supervised by a well-trained volunteer or physical therapy student.

Key Elements:

• Individual risk factor assessment, treatment, and/or referral by a physician

• Exercise classes led by a trained PT or PT student, combined with at-home exercises tailored to each participant

• Exercise intensity must increase progressively over time

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• Monthly lectures by various health professionals on topics related to falling, followed by a question and answer period

• Individual guidance on fall prevention

• Home hazards assessment and written safety recommendations

• Monthly psychosocial group sessions

Available Materials: Materials are available only in Finnish.

Study Citation: Salminen MJ, Vahlberg TJ, Salonoja MT, Aarnio PTT, Kivelä SL. Effect of a risk-based multifactorial fall prevention program on the incidence of falls. Journal of the American Geriatrics Society. 2009 Apr;57(4):612–9.

Supplemental Articles Sjösten NM, Salonoja M, Piirtola M, Vahlberg T, Isoaho R, Hyttinen H, Aarnio P, Kivelä SL. A multifactorial fall prevention programme in home-dwelling elderly people: A randomized-controlled trial. Public Health. 2007 Apr;121(4):308–18.

Sjösten NM, Salonoja M, Piirtola M, Vahlberg TJ, Isoaho R, Hyttinen HK, Aarnio PT, Kivelä SL. A multifactorial fall prevention programme in the community-dwelling aged: Predictors of adherence. European Journal of Public Health. 2007 Oct;17(5):464–70.

Vaapio S, Salminen M, Vahlberg T, Isoaho R, Aarnio P, Kivelä S-L. Effects of risk-based multifactorial fall prevention on health-related quality of life among the community-dwelling aged: A randomized controlled trial. Health and Quality of Life Outcomes. 2007 Apr;5:20–7.

Salminen M, Vahlberg T, Sihvonen S, Piirtola M, Isoaho R, Aarnio P, Kivelä SL. Effects of risk-based multifactorial fall prevention on maximal isometric muscle strength in community-dwelling aged: A randomized controlled trial. Aging Clinical and Experimental Research. 2008 Oct;20(5):487≠93.

Salminen M, Vahlberg T, Sihvonen S, Sjösten N, Piirtola M, Isoaho R, Aarnio P, Kivelä SL. Effects of risk-based multifactorial fall prevention on postural balance in the community-dwelling aged: A randomized controlled trial. Archives of Gerontology and Geriatrics. 2009 Jan-Feb;48(1):22–7.


Marika J. Salminen, PhD Family Medicine Lemminkäisenkatu 1 FI-20014 University of Turku Turku, Finland


mailto:majosa%40utu.fi?subject=

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Nijmegen Falls Prevention Program (NFPP)� for adults with Osteoporosis Smulders, et al. (2010)This study evaluated a 5½-week multicomponent falls exercise program designed to reduce falls among older adults with osteoporosis. The program consisted of six elements: 1) education, 2) an obstacle course, 3) walking exercises, 4) weight-bearing exercises, 5) correction of gait abnormalities, and 6) training for how to fall safely. Participants were 39 percent less likely to fall compared to those who did not receive the intervention.

Population: Participants were community-dwelling adults aged 65 or older with osteoporosis and a history of falls (one or more falls in the previous 12 months).

Geographic Location: Arnhem-Nijmegen, the Netherlands

Focus: Improve balance, decrease fall risk, and enhance quality of life among older adults with osteoporosis.

Program Setting: The program was conducted at a rehabilitation center in a local hospital. Participants were encouraged to incorporate walking and weight bearing exercises into their daily lives.

Content: A physical therapist (PT) and an occupational therapist (OT) led sessions twice a week for 5½ weeks. Sessions included 10 participants and consisted of one or more key elements:

• Education—60 minutes

– Explanation of osteoporosis

– Overview of medications

– Simulations of situations in which people were likely to fall.

• An obstacle course—90 minutes

– Navigating a complex course (e.g. uneven pavement, slopes, stepping stones)

– Motor dual task (e.g., walking in pairs while holding a stick)

– Limited visual input (e.g., walking in dim light)

– Cognitive dual task (e.g., listening to a story while walking through an obstacle course)

• Walking exercises—30 minutes

– Changes in speed and direction

– Walking while handling a ball

– Following commands (e.g., stop, turn)

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• Weight-bearing exercises—15 minutes

– Walking up stairs

– Lifting and reaching exercises

• Correction of gait abnormalities—45 minutes

– Trunk extension and rotation

– Hip, knee, and ankle extension exercises

• Falling safely techniques—30 minutes

– Weight shifting

– Learning to fall sideways, forward, and backward as safely as possible

– Learning to get up safely from the ground

Session elements:

• Session 1: Education

• Session 2: Correction of gait abnormalities and obstacle course

• Session 3: Falling safely techniques , weight-bearing exercises, and walking exercises


• Session 5: Education, falling safely techniques, weight-bearing exercises, and walking exercises


• Session 7: Falling safely techniques , weight-bearing exercises, and walking exercises


• Session 9: Education, falling safely techniques, weight-bearing exercises, and walking exercises


• Session 11: Falling safely techniques and weight bearing exercises

Duration: Sessions were held twice a week for 5½ weeks. Each session lasted between 1 and 2¾ hours.

Delivered by: A PT led the walking and weight bearing exercises and the sessions devoted to correcting gait abnormalities. An OT led the educational sessions that covered home safety. The PT and OT jointly delivered the initial education session, the obstacle course, and the training in how to fall safely.

The PTs and OTs attended a two-day training course that covered the theoretical and practical background of the program. The PTs attended an additional one-day course on functional walking.

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Minimum Level of Training Needed: This program should be delivered by a PT and OT with additional training in teaching older adults with osteoporosis how to fall safely.

Key Elements:

• The obstacle course, especially the emphasis on dual task activities.

• Training in teaching older adults with osteoporosis how to fall safely.

• Walking exercises in a distracting environment.

Available Materials: No materials were available at the time of publication.

Study Citation: Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Archives of Physical Medical Rehabilitation. 2010;91(11):1705–11.

Supplemental ArticlesWeerdesteyn V, Rijken H, Geurts AC, Smits-Engelsman BC, Mulder T, Duysens J. A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly. Gerontology. 2006;52(3):131–41.

Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. The development of a multi-modal fall prevention program for persons with osteoporosis M.L. Vincent, T.M. Moreau (Eds.), Accidental falls: causes, preventions and interventions, Nova Publisher Inc, New York (2008), pp. 185–201.


Ellen Smulders, PhD Senior Researcher Tolbrug Tolbrug Specialistische Revalidatie Henri Dunantstraat 7 5223 GZ ’s-Hertogenbosch P.O. Box 90153 5200 ME ’s-Hertogenbosch The Netherlands

Tel: 0031 73 553 57 13 Email: [email protected]

5200 ME ’s-Hertogenbosch Website: www.tolbrug.nl

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The Winchester Falls Project Spice, et al. (2009) This study evaluated the effectiveness of two fall interventions. The primary care intervention consisted of fall risk assessments by nurses followed by referrals to other professionals. The secondary care intervention involved multidisciplinary fall risk assessments [by a physician, nurse, physical therapist (PT), and occupational therapist (OT)], followed by appropriate interventions and follow-up if necessary. Only the secondary care intervention was effective in reducing falls.

Compared to the group who received usual care, participants in the secondary care multidisciplinary intervention were half as likely to fall, a third less likely to sustain a fall-related fracture, and 55 percent less likely to die in the year following the intervention.

Population: Participants were community-dwelling adults aged 65 or older who had sustained two or more falls in the previous year. About three-quarters were female.

Geographic Locale: Mid Hampshire, United Kingdom

Focus: Assess fall risk factors and provide individualized interventions.

Program Setting: Baseline assessments were conducted in a multidisciplinary clinic with referrals for interventions and follow-up if necessary.

Content: Participants received a standardized assessment for fall risk factors that included psychoactive medications; visual impairment; neurological, musculoskeletal, and/or cardiovascular problems; poor mobility; postural hypotension; improper footwear; environmental hazards; and alcohol use.

Individualized interventions included medication changes; physical therapy interventions such as strength, balance, and gait training; occupational therapy interventions such as corrective shoes, adaptive equipment, and home visits to reduce fall hazards; nursing interventions such as monitoring postural hypotension; and social services interventions such as increasing home help.

131



Assessed by physician:

General medical history and examination Refer to appropriate specialists

Medications

Stop medications when possible; add medication where appropriate; make recommendations to primary care physician; reduce or stop psychoactive medications

Visual impairmentRecommend optician if one has not been seen in 2 years or if there is a change in vision; refer to ophthalmologist when appropriate (e.g., cataracts)

Alcohol use Advise to reduce or stop

Assessed by a nurse:

Postural hypotension Refer to primary care nurse for monitoring

Review of continence Refer to community nurse

Assessed by a PT:

Poor mobilityPhysical therapy interventions such as strength, balance, and gait training; exercise instruction; provide mobility aids

Assessed by an OT:

Improper footwear Information on footwear; refer for orthotics or corrective shoes

Environmental hazards

In-home visit; suggest adaptive equipment; recommend grab bars; refer to local organizations specializing in home safety assessments for security advice, and to install window or door locks, security lights, smoke alarms etc., if necessary

Personal and domestic activities of daily living

Daily living advice; refer to social services for assistance

132


Duration: Fall risk assessments took about two hours. The amount and duration of the follow-up interventions varied by the type of interventions received.

Delivered by: Assessments and individualized interventions were implemented by physicians, nurses, PTs, and OTs.

Minimum Level of Training Needed: This intervention requires a variety of highly trained health care professionals. Preparation for conducting the baseline assessments requires a half-day training session.

Key Elements: Physicians, nurses, PTs, and OTs used a structured in-depth assessment instrument.

Available Materials: Structured assessment instrument

*See Appendix C-9.

Study Citation: Spice CL, Morotti W, George S, Dent THS, Rose J, Harris S, Gordon CJ. The Winchester falls project: A randomised controlled trial of secondary prevention of falls in older people. Age and Aging. 2009 Jan;38(1):33–40.


Dr. Claire Spice Department of Medicine for Older People Portsmouth Hospitals NHS Trust Queen Alexandra Hospital Southwick Hill139 Cosham PO6 3LY, United Kingdom


mailto:claire.spice%40porthosp.nhs.uk?subject=

133


Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques)� Tinetti, et al. (1994)This study used a tailored combination of intervention strategies based on an assessment of each participant’s fall risk factors. Participants were about 30 percent less likely to fall compared with people who did not receive the intervention.

Population: Participants were members of a health maintenance organization. All were 70 or older and lived in the community. Most participants were female.

Geographic Locale: Farmington, Connecticut, United States

Focus: Identify and modify each participant’s risk factors.

Program Setting: The intervention was delivered to participants in their homes.

Content: This program provided an individualized intervention for each participant. The content varied based on the fall risk factors identified. Possible intervention components included medication adjustment, recommendations for behavioral change, education and training, home-based physical therapy, and a home-based progressive balance and strengthening exercise program.

The selection of interventions was guided by decision rules and priorities. No participant received more than three balance and strength training programs.

134



Assessed by a nurse practitioner:

Postural hypotension Behavioral recommendations such as elevating the head of the bed and using ankle pumps; made changes in medications

Use of sedative-hypnotic medication Education; discontinued medication; non-pharmacological alternatives

Use of 4+ prescription medications

Reviewed medications with primary physician; the final decision on medication changes was made by the primary physician

Inability to transfer safely to bathtub or toilet

Training in transfer skills; home modifications (e.g., installing grab bars and a raised toilet seat)

Environmental hazards Home modifications (e.g., removing rugs and installing railings)

Assessed by a physical therapist:

Gait impairments Gait training; use of assistive devices; balance and/ or strengthening exercises

Impairments in transfer skills or balance

Training in transfer skills; home modifications; balance exercises (progressing through 4 levels of difficulty)

Impairment in leg or arm strength or in range of motion

Progressive strengthening exercises with resistance bands and putty, increasing resistance after participant could complete 10 repetitions; exercises were performed for 15–20 minutes twice a day

Duration: The intervention was conducted over a three-month period. The amount and duration of contacts varied by the type of interventions received.

Delivered by: A nurse practitioner and physical therapist (PT) conducted the risk factor assessments. Medication adjustments were undertaken in cooperation with the participant’s primary physician who made the final decision on medication changes. The PT conducted all physical therapy and supervised exercise sessions.

Minimum Level of Training Needed: The assessment requires at least a well-trained paraprofessional such as a PT assistant or licensed practical nurse (LPN). The intervention needs at least a BA-level nurse. The physical therapy portion requires a PT or OT, or a PT or OT assistant with supervision by a PT or OT.

Key Elements: The assessments need to be clearly linked to the intervention components. The minimum risk factor interventions include (1) postural blood pressure and behavioral recommendations; (2) medication review and reduction (especially psychoactive medications); (3) balance, strength, and gait assessments and interventions; and (4) environmental assessment and modification.

135


It is essential that the progressive balance and strength exercise program includes both supervised and at-home (unsupervised) components.

Available Materials: Intervention materials including risk factor assessments and treatment worksheets, medication reduction strategies, balance exercises, home safety checklists, and information sheets can be requested through the intervention web site www.fallprevention.org.

Study Citation: Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, Koch ML, Trainor K, Horwitz RI. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine. 1994 Sept 29;331(13):821–7.

Supplemental Articles Koch M, Gottschalk M, Baker DI, Palumbo S, Tinetti ME. An impairment and disability assessment and treatment protocol for community-living elderly persons. Physical Therapy. 1994 Apr;74(4):286–94.

Tinetti ME, Baker DI, Garrett PA, Gottschalk M, Koch ML, Horwitz RI. Yale FICSIT: Risk factor abatement strategy for fall prevention. Journal of the American Geriatrics Society. 1993 Mar;41(3):315–320.


Mary Tinetti, MD Department of Epidemiology and Public Health Yale University School of Medicine I Internal Medicine-Geriatrics PO Box 208025 New Haven, CT 06520-8025, United States


www.fallprevention.org

mailto:mary.tinetti%40yale.edu?subject=

136


A Multifactorial Program Wagner, et al. (1994) This study tested a moderate-intensity intervention that used tailored strategies based on assessments of each participant’s risk factors. After one year, participants were 10 percent less likely to fall and 5 percent less likely to have an injurious fall, compared with people who received usual medical care.

Population: All participants were 65 or older and lived in the community. About 60 percent of participants were female.

Geographic Locale: Seattle, Washington, United States

Focus: Reduce disability and/or falls by: improving physical fitness, modifying excessive alcohol use, improving home safety, reducing psychoactive medication use, and improving hearing and vision.

Program Setting: Participants received the assessments and interventions from a nurse at local health maintenance organization (HMO) centers. Participants conducted a home assessment or had it done by a family member or volunteer.

Content: The assessments consisted of simple screening tests for 6 risk factors. The intervention content varied based on the individual’s risk factors.


Inadequate exerciseParticipated in a two-hour exercise orientation class testing fitness, given exercise instruction, and encouraged to begin a program of brisk walking

Use of psychoactive drug Reviewed medications using a pharmacist and sent written recommendations to the participant’s primary care provider

Impaired visionCorrected when possible. Participants with uncorrectable visual impairments received information about available community resources

Impaired hearing Had a hearing aid evaluation. Program provided behavioral intervention classes for participants with uncorrectable deficits

Excessive alcohol useReferred to an alcohol treatment program if alcoholism was suspected, or given an instructional booklet that provided strategies for limiting use

Home hazards Assessed home safety using an instructional home safety checklist

137


Duration: The initial visit consisted of a 1- to 1½-hour interview. The length and number of subsequent sessions varied by the type of interventions selected for each participant.

Delivered by: The program was delivered by a single nurse educator who received brief training by the research team. There was no formal curriculum because only one nurse was involved. Either trained volunteers or participants’ family members completed the home safety assessment using the provided checklist.


Key Elements: The nurse’s follow-up phone contacts and home visits may have had positive effects on participants’ health that were independent of the interventions for specific risk factors.

Available Materials: No intervention materials were available for distribution at the time of publication.

Study Citation: Wagner EH, LaCroix AZ, Grothaus L, Leveille SG, Hecht J, Artz K, Odle K, Buchner DM. Preventing disability and falls in older adults: A population-based randomized trial. American Journal of Public Health. 1994 Nov;84(11):1800–6.


Edward H. Wagner, MD, MPH Group Health Research Institute 1730 Minor Avenue, Ste. 1290 Seattle, WA 98101, United States

Tel: 206-287-2877 E-mail: [email protected]

mailto:wagner.e%40ghc.org?subject=

138


The following three tables summarize the study population characteristics, study methodology, and intervention characteristics for the 12 Multifaceted Interventions.

139


Tab

le 1

. S

um

mar

y Ta

ble

of

Stu

die

s an

d S

tud

y P

op

ula

tio

n C

har

acte

rist

ics

Stud

yN

o . S

tud

y Pa

rtic

ipan

tsM

ean

Age

%

Fem

ale

Rac

e/Et

hnic

ity

Soci

oeco

nom

ic S

tatu

s (S

ES)

Prev

ious

Fal

lsO

ther

C

hara

cter

isti

cs

Clem

son

2004

310

7874

%N

A*52

% h

ad b

elow

ave

rage

w

eekl

y in

com

e65

% fe

ll in

pas

t yea

r

Clos

e 19

9939

778

68%

NA

NA

65%

fell

in p

ast y

ear

61%

live

d al

one

Dav

ison

200

531

377

72%

Mos

t wer

e W

hite

; no

ne w

ere

Asi

an

or B

lack

70%

edu

cati

on <

8th

grad

e

4% e

duca

tion

>H

S

Part

icip

ants

incl

uded

all

soci

al c

lass

es

100%

fell

in p

ast y

ear;

aver

age

was

3 fa

lls

Day

200

21,

090

7660

%77

% b

orn

in

Aus

tral

iaSt

udy

cond

ucte

d in

mai

nly

mid

dle

clas

s ar

ea6%

fell

in p

ast m

onth

54%

live

d al

one

47%

mar

ried

Loga

n 20

1020

482

.565

99%

Whi

te53

% U

nski

lled

wor

kers

or

neve

r wor

ked

100%

fell

in p

ast 3

m

onth

s; 7

2% h

ad ≥

2 fa

lls in

pas

t 3 m

onth

s 2

56%

of i

nter

vent

ion

and

66%

of c

ontr

ol

lived

alo

ne

Palv

anen

201

41,

314

77.6

86%

100%

Whi

teA

ll pa

rtic

ipan

ts w

ere

reti

red

and

rece

ived

sta

te

ben

efit

s

36%

fell

in p

ast 6

m

onth

sM

ean

num

ber

of

med

icat

ions

= 5

.6

Salm

inen

200

959

174

84%

100%

Whi

te27

% e

duca

tion

>6t

h gr

ade

72%

com

plet

ed 6

th g

rade

2% e

duca

tion

<6t

h gr

ade

All

part

icip

ants

wer

e re

tire

d

100%

fell

in p

ast y

ear

41%

fell

once

in p

ast

year

53%

live

d al

one

45%

mar

ried

Smul

ders

201

096

7194

%10

0% W

hite

NA

100%

Spic

e 20

0937

582

74%

Mos

t wer

e W

hite

NA

100%

≥2

falls

in p

ast

year

59%

live

d al

one

Tine

tti 1

994

301

7869

%N

A31

% e

duca

tion

>H

S43

% fe

ll in

pas

t yea

r44

% m

arri

ed

Wag

ner 1

994

1,55

973

59%

93%

Whi

te25

% e

duca

tion

>16

yea

rs

35%

inco

me

<$15

,000

33%

fell

in p

ast y

ear

*No

info

rmat

ion

avai

labl

e

140


ble

2.

Stu

dy

Met

ho

do

log

y

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Clem

son

2004

Sydn

ey, A

ustr

alia

Com

mun

ity

resi

dent

s re

crui

ted

thro

ugh

refe

rral

s,

adve

rtis

emen

ts, &

co

mm

unit

y or

gani

zati

ons

Age

>70

, had

fell

in p

ast

year

or h

ad a

fear

of f

allin

g,

spok

e En

glis

h

Cogn

itiv

ely

impa

ired

or

hom

ebou

ndN

o

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

mai

led

in a

pr

e-ad

dres

sed,

sta

mp

ed

cale

ndar

eac

h m

onth

.

14 m

onth

sFa

ll ra

te, o

vera

ll RR

b = 0

.69

(0.5

0–0.

96)

Non

e

Fall

rate

, mal

es

RRb =

0.3

2 (0

.17–

0.59

)

Fall

rate

, fem

ales

RRb =

0.9

6 (0

.50–

1.85

)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Dav

ison

200

5N

ewca

stle

, Uni

ted

King

dom

Com

mun

ity

seni

ors

trea

ted

in E

Ds

for a

fall

wer

e m

aile

d a

surv

ey to

det

erm

ine

thei

r fa

ll hx

. Rep

eat f

alle

rs w

ere

recr

uite

d by

tele

phon

e.

Age

>65

trea

ted

in E

D fo

r a

fall

or fa

ll in

jury

, & w

ho h

ad

a fa

ll in

pas

t yea

r

Cogn

itiv

ely

impa

ired

, ha

d >1

pre

viou

s ep

isod

e of

syn

cop

e,

imm

obile

, blin

d,

apha

sic,

or h

ad a

cle

ar

med

ical

exp

lana

tion

fo

r the

ir fa

ll

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

com

plet

ed

wee

kly

fall

diar

ies

that

th

ey re

turn

ed e

very

mon

th

for 1

2 m

onth

s. A

fter

1 y

ear,

all p

arti

cipa

nts’

hos

pita

l re

cord

s w

ere

revi

ewed

for

falls

.

12 m

onth

sN

umb

er o

f fal

ls

RRd =

0.6

4 (0

.46–

0.90

)N

one

Num

ber

of f

alle

rsRR

d = 0

.95

(0.8

1–1.

12)

Nec

k or

fem

ur fr

actu

res

RRd =

0.4

8 (0

.04–

5.29

)

Oth

er fr

actu

reRR

d = 0

.53

(0.2

0–1.

39)

Fall-

rela

ted

ED v

isit

RRd =

0.9

0 (0

.55–

1.47

)

Fall-

rela

ted

hosp

ital

ad

mis

sion

RRd =

0.8

0 (0

.41–

1.56

)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

141


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Day

200

2M

elb

ourn

e, A

ustr

alia

Iden

tifi

ed fr

om e

lect

oral

ro

ll &

thro

ugh

gene

ral

prac

titi

oner

s. S

ubje

cts

wer

e se

nt le

tter

s &

then

co

ntac

ted

by te

leph

one.

Age

≥70

, ow

ned

or le

ased

ho

me

& a

ble

to m

ake

hom

e m

odif

icat

ions

Plan

ning

to m

ove

w/i

n 2

year

s; re

cent

ph

ysic

al a

ctiv

ity

w/

a ba

lanc

e co

mp

onen

t; un

able

to w

alk

10

–20

m w

/o re

st,

help

, or a

ngin

a; s

ever

e re

spir

ator

y or

car

diac

di

seas

e; c

ogni

tive

ly

impa

ired

; mad

e re

cent

maj

or h

ome

mod

ific

atio

ns; o

r did

no

t hav

e ph

ysic

ian

appr

oval

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

cal

enda

r p

ostc

ards

com

plet

ed

daily

& re

turn

ed b

y m

ail.

If no

t rec

eive

d w

ithi

n 5

wor

king

day

s af

ter e

nd o

f m

onth

, par

tici

pant

was

in

terv

iew

ed b

y te

leph

one.

18 m

onth

sFa

ll ra

tes

Exer

cise

alo

ne:

RRb =

0.8

2 (0

.70–

0.97

) N

one

Exer

cise

+ v

isio

n:

RRb =

0.7

3 (0

.58–

0.91

)

Exer

cise

+ h

ome

mod

: RR

b = 0

.76

(0.6

0–0.

95)

Exer

cise

+ v

isio

n +

hom

e m

od:

RRb =

0.67

(0.5

1–0.

88)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

142


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Loga

n 20

10N

otti

ngha

msh

ire,

UK

Not

ting

ham

shir

e, U

K; w

/in

prim

ary

trus

t of N

otti

ngha

m

City

, Rus

hclif

fe, B

roxt

owe

and

Huc

knal

l, an

d G

edlin

g.

Incl

udes

cit

y, s

ubur

ban,

and

ru

ral p

opul

atio

ns. R

ecru

ited

ov

er 1

6 m

onth

s b

egin

ning

in

Sep

200

5

Age

≥60

, in

the

geog

raph

ic

area

of i

nter

est,

had

calle

d th

e Ea

st M

idla

nd

Am

bula

nce

Serv

ice

bec

ause

of a

fall

but w

as

not t

aken

to th

e ho

spit

al

Una

ble

to g

ive

cons

ent,

too

ill to

pa

rtic

ipat

e, o

r alr

eady

in

a fa

lls p

reve

ntio

n re

habi

litat

ion

prog

ram

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

diar

y w

/ te

leph

one

follo

w-u

p if

need

ed

12 m

onth

sFa

ll ra

te

IRRa

=0.

45 (0

.35–

0.58

) N

one

Tim

e to

firs

t fal

l H

Rc 0

.20

(0.2

3–0.

44)

Num

ber

of f

alle

rsRR

d=0.

56 (0

.78–

0.94

)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Palv

anen

201

4Ta

mp

ere

and

Lapp

eenr

anta

, Fin

land

Refe

rred

to c

linic

by

self,

re

lati

ve o

r pri

mar

y ca

re

doct

or

Com

mun

ity-

dwel

ling

aged

≥70

, 1 fa

ll ri

sk fa

ctor

: m

obili

ty is

sues

, ≥3

falls

in

past

12

mon

ths,

pre

viou

s fr

actu

re, h

ip fr

actu

re

in 1

st d

egre

e re

lati

ve,

oste

opor

osis

, low

bod

y w

eigh

t, or

illn

ess

that

in

crea

sed

the

risk

of f

alls

, fr

actu

re o

r ost

eop

oros

is

Inab

ility

to g

ive

cons

ent,

disa

bilit

ies

that

pre

vent

ed

phys

ical

act

ivit

y, o

r te

rmin

al il

lnes

s

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Colle

cted

eve

ry 3

mon

ths

usin

g te

leph

one

inte

rvie

ws

& d

urin

g cl

inic

vis

its.

12 m

onth

sFa

ll ra

te

IRRa

=0.

72 (0

.61–

0.91

)N

one

Fall

rate

HRc

=0.

78 (0

.67–

0.91

)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

143


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Salm

inen

200

9 Po

ri, F

inla

ndA

nnou

ncem

ents

in lo

cal

new

spap

ers,

pha

rmac

ies,

he

alth

cen

ters

, hos

pita

ls, &

pr

ivat

e cl

inic

s; a

lso

thro

ugh

wri

tten

invi

tati

ons

from

he

alth

pro

fess

iona

ls

Age

65+

, ≥1

fall

in p

ast

year

, lit

tle

or n

o co

gnit

ive

impa

irm

ent (

MM

SE ≥

17),

livin

g in

com

mun

ity

or

in h

ousi

ng th

at p

rovi

ded

occa

sion

al a

ssis

tanc

e

Cogn

itiv

ely

impa

ired

, un

able

to w

alk

10 m

in

dep

ende

ntly

w/ o

r w

/o w

alki

ng a

ids

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Part

icip

ants

mai

led

fall

diar

ies

mon

thly

. If o

ne w

as

not r

ecei

ved,

par

tici

pant

s w

ere

rem

inde

d by

te

leph

one.

Par

tici

pant

s al

so re

por

ted

falls

as

they

oc

curr

ed b

y ph

one

to

rese

arch

ass

ista

nts.

12 m

onth

sFa

ll ra

te fo

r par

tici

pant

s w

/ ≥

3 fa

lls in

pre

viou

s ye

ar

IRRa

= 0

.59

(0.3

8–0.

91)

2 pa

rtic

ipan

ts

stop

ped

whi

le

exer

cisi

ng

bec

ause

they

fe

lt u

nwel

l

3 fa

lls w

/o in

jury

oc

curr

ed d

urin

g ex

erci

se

Fall

rate

for p

arti

cipa

nts

w/ m

ore

sym

ptom

s of

de

pres

sion

IRRa

= 0

.50

(0.2

8–0.

88)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Smul

ders

201

0N

ijmeg

an, N

ethe

rlan

dsId

enti

fied

from

dat

abas

es o

f D

XA

sca

ns, m

ail t

o m

emb

ers

of D

utch

Ost

eop

oros

is

Pati

ent C

ounc

il, b

y ad

vert

isin

g

Age

≥65

, com

mun

ity-

dwel

ling,

w/ o

steo

por

osis

(D

XA

fem

oral

nec

k or

low

er

back

T-s

core

-2.5

), 1

fall

in

past

yea

r, &

abl

e to

wal

k 15

min

w/o

a w

alki

ng a

id

Seve

re c

ardi

ac,

pulm

onar

y, o

r m

uscu

losk

elet

al

diso

rder

s or

dis

orde

rs

asso

ciat

ed w

/ hi

gher

fall

risk

(e.g

. ne

urol

ogic

dis

orde

rs)

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

cale

ndar

w/

follo

w-u

p ph

one

call

if ne

cess

ary

12 m

onth

sFa

ll ra

teRR

b=

0.6

1 (0

.40–

0.94

) N

one

Num

ber

of f

alle

rsRR

d=

0.8

7 (0

.56–

1.34

)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

144


udy

Loca

tion

Stud

y Po

pul

atio

n &

R

ecru

itm

ent

Incl

usio

n C

rite

ria

Excl

usio

n C

rite

ria

Def

ined

Fal

ls

Spic

e 20

09N

ijmeg

an, N

ethe

rlan

dsId

enti

fied

from

dat

abas

es o

f D

XA

sca

ns, m

ail t

o m

emb

ers

of D

utch

Ost

eop

oros

is

Pati

ent C

ounc

il, b

y ad

vert

isin

g

Age

≥65

, com

mun

ity-

dwel

ling,

w/ o

steo

por

osis

(D

XA

fem

oral

nec

k or

low

er

back

T-s

core

-2.5

), 1

fall

in

past

yea

r, &

abl

e to

wal

k 15

min

w/o

a w

alki

ng a

id

Seve

re c

ardi

ac,

pulm

onar

y, o

r m

uscu

losk

elet

al

diso

rder

s or

dis

orde

rs

asso

ciat

ed w

/ hi

gher

fall

risk

(e.g

. ne

urol

ogic

dis

orde

rs)

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mon

thly

fall

cale

ndar

w/

follo

w-u

p ph

one

call

if ne

cess

ary

12 m

onth

sFa

ll ra

teRR

= 0

.76

(0.5

8–0.

98)

Non

e

Fall

per

per

son-

wee

kRR

= 0

.69

(0.5

2–0.

90)

Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Tine

tti 1

994

Sout

hern

Con

nect

icut

, U

nite

d St

ates

Mem

ber

s of

an

HM

O,

cont

acte

d fir

st b

y le

tter

&

then

scr

eene

d by

tele

phon

e

Age

≥70

, am

bula

tory

in

own

hom

e, h

ad a

t lea

st

1 of

9 ri

sk fa

ctor

s (p

ostu

ral

hyp

oten

sion

, use

d se

dati

ves,

≥4

med

icat

ions

, in

abili

ty to

tran

sfer

, ga

it im

pair

men

t, lo

ss

of s

tren

gth

or ra

nge

of

mot

ion,

hom

e ha

zard

s)

Cogn

itiv

ely

impa

ired

or

had

par

tici

pate

d in

vig

orou

s sp

orts

or

wal

king

for e

xerc

ise

in

past

mon

th

No

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

A m

onth

ly fa

lls c

alen

dar

was

retu

rned

by

mai

l. If

not r

ecei

ved

or if

it

indi

cate

d a

fall,

par

tici

pant

w

as in

terv

iew

ed b

y te

leph

one.

12 m

onth

sFa

ll ra

te

RR =

0.7

6 (0

.58–

0.98

) N

one

Fall

per

per

son-

wee

kRR

= 0

.69

(0.5

2–0.

90)

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

145


Stud

yLo

cati

onSt

udy

Pop

ulat

ion

&

Rec

ruit

men

tIn

clus

ion

Cri

teri

aEx

clus

ion

Cri

teri

aD

efin

ed F

alls

Wag

ner 1

994

Seat

tle,

Was

hing

ton,

U

nite

d St

ates

Rand

om s

ampl

e of

H

MO

mem

ber

s se

nt a

n in

trod

ucto

ry le

tter

follo

wed

by

a m

ail q

uest

ionn

aire

Age

65+

, am

bula

tory

, &

inde

pen

dent

in A

DLs

Inst

itut

iona

lized

or

seri

ousl

y ill

Yes

Met

hod

of R

ecor

din

g Fa

llsLe

ngth

of F

ollo

w-u

pM

easu

red

Out

com

esR

esul

ts*

Ad

vers

e Ef

fect

s

Mai

led

surv

ey a

t bas

elin

e,

at 1

& 2

yea

rs. I

f not

re

turn

ed, p

arti

cipa

nts

wer

e in

terv

iew

ed b

y te

leph

one.

Fal

l inj

urie

s w

ere

iden

tifi

ed th

roug

h se

lf-re

por

t & h

ospi

tal

disc

harg

e fil

es.

24 m

onth

sD

iffe

renc

e in

% fa

lling

N

one

Falls

, Yea

r 19.

3% (4

.1–1

4.5)

Falls

, Yea

r 2+2

.2%

n.s

Falls

w/ i

njur

y, Y

ear 1

-4.6

% (p

<0.

01)

Falls

w/ i

njur

y, Y

ear 2

+3.3

% n

.s.

a In

cide

nce

Rate

Rat

io

b Re

lativ

e Ra

te

c H

azar

d Ra

tio

d Re

lativ

e Ri

sk

e Ra

te R

atio

per

1,0

00 h

rs o

f act

ivit

y f O

dds R

atio

146


ble

3.

Inte

rven

tio

n C

har

acte

rist

ics

Stud

yFo

cus

Prov

ider

sSt

ruct

ure

Num

ber

of S

essi

ons

Prov

ider

Con

tact

Ti

me

Clem

son

2004

Lear

n fa

ll pr

even

tion

tech

niqu

es,

impr

ove

self-

effic

acy,

& m

ake

beh

avio

ral c

hang

es

Occ

upat

iona

l th

erap

ist &

team

of

trai

ned

cont

ent

exp

erts

Smal

l gro

up c

lass

es7

wee

kly

2-ho

ur c

lass

es

1 ho

me

visi

t 6 w

eeks

aft

er

the

final

cla

ss

1 b

oost

er s

essi

on 3

mon

ths

afte

r the

fina

l cla

ss

1 m

edic

al a

sses

smen

t

Clas

ses:

14

hour

s

Hom

e vi

sit:

1 to

1½

hou

rs

Boos

ter:

1½ h

ours

Clos

e 19

99Id

enti

fy m

edic

al ri

sk fa

ctor

s &

ho

me

haza

rds,

pro

vide

refe

rral

s &

reco

mm

enda

tion

s to

redu

ce

fall

risk

, & im

prov

e ho

me

safe

ty

Phys

icia

n &

oc

cupa

tion

al

ther

apis

t

One

-on-

one

1 ho

me

asse

ssm

ent

1 m

edic

al a

sses

smen

t

Hom

e as

sess

men

t:

1 ho

ur

Med

ical

ass

essm

ent:

45

min

utes

Dav

ison

200

5Id

enti

fy &

mod

ify

each

pa

rtic

ipan

t’s fa

ll ri

sk fa

ctor

sPh

ysic

ian,

phy

sica

l th

erap

ist,

&

occu

pati

onal

th

erap

ist

Hos

pita

l-ba

sed

med

ical

exa

m &

tr

eatm

ent f

ollo

wed

by

PT

& O

T in

-hom

e as

sess

men

ts &

risk

fa

ctor

redu

ctio

n

2 ho

spit

al s

essi

ons

2 ph

ysic

al th

erap

y vi

sits

1 oc

cupa

tion

al th

erap

y vi

sit w

/ 1 fo

llow

-up

visi

t

15 w

eekl

y 1-

hour

cla

sses

Med

ical

ass

essm

ent:

1

hour

Med

ical

inte

rven

tion

: 20

min

utes

PT a

sses

smen

t:

45 m

inut

es

PT in

terv

enti

on: 1

5 m

inut

es

OT

asse

ssm

ent:

45

min

utes

Follo

w-u

p vi

sit:

20

min

utes

Clas

ses:

15

hour

s

Day

200

2Im

prov

e st

reng

th &

bal

ance

, im

prov

e p

oor v

isio

n, &

redu

ce

hom

e ha

zard

s

Stat

e ac

cred

ited

tr

aine

d fo

r the

in

terv

enti

on

Gro

up e

xerc

ise

clas

ses

Visi

on a

sses

smen

t &

trea

tmen

t, ho

me

asse

ssm

ent &

mod

ific

atio

n

Visi

on m

anag

emen

t: N

A

Hom

e m

odif

icat

ion:

N

A

147


Stud

yFo

cus

Prov

ider

sSt

ruct

ure

Num

ber

of S

essi

ons

Prov

ider

Con

tact

Ti

me

Loga

n 20

10Re

duce

risk

y b

ehav

iors

, im

prov

e ph

ysic

al fi

tnes

s, &

redu

ce h

ome

haza

rds

Occ

upat

iona

l th

erap

ist,

phys

ical

th

erap

ist,

& n

urse

One

-on-

one

w/

opti

onal

gro

up

clas

ses

12 t

wic

e w

eekl

y 2-

hour

cl

asse

s

6 or

mor

e 1-

hour

PT

hom

e vi

sits

11 h

ome

asse

ssm

ent

1 m

edic

al a

sses

smen

t

Clas

ses:

24

hour

s

Phys

ical

ther

apy:

6

hour

s

Hom

e as

sess

men

t:

1 ho

ur

Med

ical

Ass

essm

ent:

1 ho

ur

Palv

anen

201

4Id

enti

fy &

mod

ify

each

pa

rtic

ipan

ts fa

ll ri

sk fa

ctor

s A

phy

sici

an, P

T, &

nu

rse

Ass

essm

ent:

One

-on

one

Inte

rven

tion

: va

ried

by

typ

e of

in

terv

enti

on

Ass

essm

ent:

3 ho

urs

Inte

rven

tion

: var

ied

by t

ype

& n

umb

er o

f in

terv

enti

ons

rece

ived

Vari

ed

Salm

inen

200

9A

sses

s &

add

ress

eac

h pa

rtic

ipan

t’s fa

ll ri

sk fa

ctor

s,

impr

ove

phys

ical

fitn

ess,

pro

vide

in

form

atio

n &

cou

nsel

ing

on

fall

prev

enti

on, a

sses

s &

mod

ify

hom

e ha

zard

s, &

pro

vide

ps

ycho

logi

cal s

upp

ort

Ger

iatr

icia

n, tr

aine

d pu

blic

hea

lth

nurs

e,

trai

ned

nurs

ing

stud

ents

, phy

sica

l th

erap

ist,

& v

ario

us

heal

th p

rofe

ssio

nals

One

-on-

one

com

bine

d w

/ gro

up

clas

ses

1 fa

ll ris

k as

sess

men

t

1 co

unse

ling

& in

form

atio

n se

ssio

n

1 ho

me

asse

ssm

ent

12 1

-hou

r hea

lth le

ctur

es

12 1

-hou

r psy

chos

ocia

l gr

oup

sess

ions

45- t

o 50

-min

ute

grou

p ex

erci

se c

lass

es e

very

2

wee

ks fo

r 26

wee

ks

Hom

e ex

erci

ses

3 tim

es a

w

eek

for 5

2 w

eeks

Risk

ass

essm

ent:

45

min

utes

Coun

selin

g: 4

5 m

inut

es

Hom

e as

sess

men

t:

45 m

inut

es

Hea

lth

lect

ures

: 12

hou

rs

Psyc

hoso

cial

gro

up

sess

ions

: 12

hour

s

Exer

cise

cla

sses

: 10

–11

hour

s

Smul

ders

201

0Im

prov

e ba

lanc

e, d

ecre

ase

fall

risk

, & im

prov

e qu

alit

y of

life

for

wom

en w

/ ost

eop

oros

is.

A p

hysi

cal t

hera

pist

&

occ

upat

iona

l th

erap

ist

Gro

up e

duca

tion

&

exer

cise

s11

ses

sion

s co

mpr

ised

of

edu

cati

on, e

xerc

ise

&

obst

acle

cou

rse

navi

gati

on

Sess

ions

: 18

½ h

ours

148


udy

Focu

sPr

ovid

ers

Stru

ctur

eN

umb

er o

f Ses

sion

sPr

ovid

er C

onta

ct

Tim

e

Spic

e 20

09A

sses

s fa

ll ri

sk fa

ctor

s &

pro

vide

in

divi

dual

ized

inte

rven

tion

sD

octo

r, nu

rse,

ph

ysic

al th

erap

ist,

& o

ccup

atio

nal

ther

apis

t

One

-on-

one

asse

ssm

ent

w/ f

ollo

w-u

p in

terv

enti

ons

1 fa

ll ri

sk a

sses

smen

t

Leng

th &

num

ber

of

subs

eque

nt s

essi

ons

vari

ed

by t

ype

of in

terv

enti

on(s

)

Risk

ass

essm

ent:

2

hour

s

Inte

rven

tion

: var

ied

Tine

tti 1

994

Iden

tify

& m

odif

y ea

ch

part

icip

ant’s

fall

risk

fact

ors

Med

icat

ion

adju

stm

ents

co

ordi

nate

d w

/ pa

rtic

ipan

t’s p

rim

ary

phys

icia

n, e

xerc

ise

cond

ucte

d by

PT

Vari

ed b

y ty

pe

of

inte

rven

tion

Vari

ed b

y ty

pe

& n

umb

er

of in

terv

enti

ons

rece

ived

Vari

ed

Wag

ner 1

994

Redu

ce d

isab

ility

&/o

r fal

ls b

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149

AppendicesAppendix A: Intervention Study selection process

ToC3

APPENDICES

Appendix A: Intervention Study Selection Process In 2003, the RAND Corporation was commissioned by the Centers for Medicare and Medicaid Services (CMS) to review and analyze the existing research on fall prevention interventions. They conducted a comprehensive literature search and reviewed 826 intervention studies, of which 95 met the following selection criteria: (1) included adults aged ≥65 years; (2) used a randomized controlled trial or controlled clinical trial study design; (3) identified falls as an outcome; and (4) measured the number of falls at least three months after the start of the intervention. Of the 95 studies, 57 had falls as a primary outcome and 38 of the 57 reported either the number of subjects who fell at least once or the monthly rate of falling. RAND included these 38 studies in their meta-analyses to determine the effectiveness of fall prevention interventions (categorized as exercise, education, environmental modification, or multiple component interventions).*

Beginning with the 38 studies RAND included in their meta-analysis (used by permission, L. Rubenstein, personal communication), CDC identified those that met the following inclusion criteria: (1) included community-dwelling adults aged ≥65 years; (2) used a randomized controlled study design; (3) measured falls as a primary outcome; and (4) demonstrated statistically significant positive results for at least one fall outcome (e.g., showed statistically fewer falls for intervention participants). As illustrated in Figure 1, CDC excluded one study that focused on nursing home residents, four that did not include falls as a primary outcome, and 25 that did not demonstrate statistically significant, positive results. Of the remaining eight, two described the same study and were combined. Lastly, CDC identified seven studies published after the RAND Report that met the established criteria. In total, the first edition of the Compendium included 14 studies published before December 31, 2004.

Updates in the Second EditionIn 2009, CDC undertook to update the original Compendium. A comprehensive literature search of randomized controlled trials of fall interventions published between January 1, 2005 and December 31, 2009 identified 86 studies. As Figure 2 illustrates, two interventions were excluded because they were already in the Compendium. Of the remaining 84 studies, CDC excluded 20 that were not randomized controlled trials, 15 that did not focus on community-dwelling adults aged ≥65 years, 27 that did not include falls as a primary outcome, and 14 that did not demonstrate statistically significant, positive results. In total, eight studies published between January 2005 and December 2009 were added to the Compendium.

150


Updates in the Third EditionIn 2014, CDC updated the 3nd edition of the Compendium by conducting a comprehensive literature search of randomized controlled trials of fall interventions. The search included literature published between January 1, 2009 and August 31, 2014.

MEDLINE was searched using the following terms “fall and prevention OR accidental falls [MESH]” AND “randomized control trial OR controlled clinical trial” AND “Aged”. MEDLINE search identified 386 studies. PubMed was searched with the same criteria and returned two additional, unique interventions for a total of 388.

As Figure 2 illustrates, 39 interventions were excluded as duplicate listings in MEDLINE and 171 were excluded because they were not fall intervention studies (excluded studies included: cost-benefit analyses, fall RCT protocol papers, drug trials where falls were a side effect, and cross-sectional papers that used RCT data). Of the remaining 178 studies, CDC excluded two that were already in the Compendium, 91 that did not include falls as an outcome (e.g., outcome measured changes in gait and balance, fear of falling, or scores on functional tests were used as proxy for fall risk), nine that were not randomized controlled trials or did not have adequate control groups (intervention did not have a placebo or usual care group e.g. compared in-person Tai Chi to a Tai Chi video intervention), 25 that did not focus on community-dwelling adults aged ≥60 years, and 36 that did not demonstrate statistically significant, positive results. In situations where the same research group had published a pilot intervention and a subsequent follow-up and both were effective at reducing falls, the follow-up paper is included and the pilots are listed as supplemental materials; three pilot interventions were excluded for this. Lastly CDC used the 2012 Cochrane review to identify clinically focused interventions that had previously been excluded. There were seven studies that met the criteria and have been added to this edition of the Compendium. In total, 19 studies, were added to the Compendium.

151

APPENDICES

Figure 1. Flow chart showing the selection process for studies used in the first edition of the Compendium

826 Fall intervention

studies

95Relavent &

rigorous studies

1Nursing home

population

25Not statistically

significant positive results

1Reported on same study

4Falls not the

primary outcome

57Falls as an outcome

38Rand Report:

Data on subjects who fell at least once or the

monthly fall rate

37 Community- dwelling

population

8Met CDC criteria

14 Compendium

studies

7Relavent, rigorous, & effective studies

published 2003–2005

152


Figure 2. Flow chart showing the selection process for studies used in the third edition of the Compendium

349 Unique studies

178Fall intervention

studies

25Not community-

dwelling adults ≥60

9Not randomized

controlled trial studies

171Not fall intervention

studies

2Intervention already

in Compendium

36Not statistically

significant positive results

3Reported on same study

85Falls as an outcome

76Randomized

controlled trial studies

51 Community-dwelling

population ≥60

15Met CDC criteria

19 Compendium

studies

7Relavent, rigorous,

& effective clinically focused studies

published 2003–2005

388Studies published

2009–2014

91Falls not and

outcome

153

APPENDICES

Appendix B: Bibliography of Compendium Studies and Supplemental Articles

Appendix B: Bibliography of Compendium Studies and Supplemental Articles

Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: A randomized controlled trial. Age and Ageing. 2003 Jul;32(4):407–14.

*Barton CJ, Bonanno D, Menz HB. Development and evaluation of a tool for the assessment of footwear characteristics. J Foot Ankle Res. 2009 Apr 23;2:10. doi: 10.1186/1757-1146-2-10.

Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year randomized controlled trial. Arch Intern Med. 2006 Feb 27;166(4):424–30.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: A randomized controlled trial. Journal of the American Geriatrics Society. 1999 Jul;47(7): 850–3.

*Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: A randomized controlled trial in women 80 years and older. Age and Ageing. 1999 Oct;28(6):513–8.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal. 1997 Oct 25;315(7115):1065–9.

Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF, Jacobs RJ, Sharp DM, Hale LA. Randomised controlled trial of prevention of falls in people aged ≥75 with severe visual impairment: The VIP trial. British Medical Journal. 2005 Oct 8;331(7520):817–20.

Clemson L, Fiatarone Singh MA, Bundy A, Cumming RG, Manollaras K, O’Loughlin P, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. British Medical Journal (Clinical research ed). 2012;345:e4547.

Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Geriatrics Society. 2004 Sep;52(9):1487–94.

Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of Falls in the Elderly Trial (PROFET): A randomized controlled trial. Lancet. 1999 Jan 9;353 (9147):93–7.

Cumming RG, Thomas M, Szonyi G, Szonyi M, Salkeld G, O’Neill E, Westburg C, Frampton G. Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society. 1999 Dec;47(12):1397–1402.

154


Davison J, Bond J, Dawson P, Steen IN, Kenny RA. Patients with recurrent falls attending accident and emergency benefit from multifactorial intervention: A randomised controlled trial. Age and Ageing. 2005 Mar;34(2):162–8.

Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomized factorial trial of falls prevention among older people living in their own homes. British Medical Journal. 2002 Jul 20;325(7356):128–33.

*Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975 Nov;12(3):189–98.

*Freiberger E, Menz HB. Characteristics of falls in physically active community-dwelling older people. Zeitschrift für Gerontologie und Geriatrie. 2006 Aug;39(4): 261–7.

Freiberger E, Menz HB, Abu-Omar K, Rütten A. Preventing falls in physically active community-dwelling older people: A comparison of two intervention techniques. Gerontology. 2007 Aug;53(5):298–305.

Gallagher JC. The effects of calcitriol on falls and fractures and physical performance tests. Journal of Steroid Biochemistry and Molecular Biology. 2004 May;89–90(1–5):497–501.

*Gallagher JC, Rapuri PB, Smith LM. An age related decrease in creatinine clearance is associated with an increase in number of falls in untreated women but not in women receiving calcitriol treatment. Journal of Clinical. Endocrinology and Metabolism. 2007 Jan 92:51–58, 2007.

*Gallagher JC, Rapuri P, Smith L. Falls are associated with decreased renal function and insufficient calcitriol production by the kidney. Journal of Steroid Biochemistry and Molecular Biology. 2007 Mar;103(3–5):610–3.

*Gardner MM, Buchner DM, Robertson MC, Campbell AJ. Practical implementation of an exercise-based falls prevention programme. Age and Ageing. 2001 Jan;30(1):77–83.

*Hagedorn R, McLafferty S, Russell D. The User Safety and Environmental Risk Checklist (USER). In: Anonymous falls: Screening and risk assessment for older people in the community. Worthing Priority Care NHS Trust. 1998:48–57.

Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, et al. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. British Medical Journal. 2010;340:c2265

Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. British Journal of Ophthalmology. 2005 Jan;89(1):53–9.

Harwood RH, Sahota O, Gaynor K, Masud T, Hosking DJ; Nottingham Neck of Femur (NONOF) Study. A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study. Age Ageing. 2004;33(1):45–51.

155

APPENDICES

Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: Results from a randomized trial. The Gerontologist. 1994 Feb;34(1):16–23.

Kemmler W, von Stengel S, Engelke K, Häberle L, Kalender WA. Exercise effects on bone mineral density, falls, coronary risk factors, and health care costs in older women: the randomized controlled senior fitness and prevention (SEFIP)study. Archives of Internal Medicine. 2010 Jan 25;170(2):179–85.

Kenny RA, Richardson DA, Steen N, Bexton RS, Shaw FE, Bond J. Carotid sinus syndrome: a modifiable risk factor for nonaccidental falls in older adults (SAFE PACE). Journal of American College of Cardiology. 2001 Nov 1;38(5):1491–6.

*Iliffe A, Kendrick D, Morris R, Skelton D, Gage H, Dinan S, Stevens Z, Pearl M, Masud T. Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: Protocol of the ProAct 65+ trial. Trials. 2010 Jan;11(1):6–10.

*Koch M, Gottschalk M, Baker DI, Palumbo S, Tinetti ME. An impairment and disability assessment and treatment protocol for community-living elderly persons. Physical Therapy. 1994 Apr;74(4):286–94.

Kovacs E, et al., Adapted physical activity is beneficial on balance, functional mobility, quality of life and fall risk in community-dwelling older women: a randomized single-blinded controlled trial. European Journal of Physical Rehabilitation Medicine. 2013;49(3):301–10

*La Grow SJ, Robertson MC, Campbell AJ, Clarke GA, Kerse NM. Reducing hazard related falls in people 75 years and older with significant visual impairment: How did a successful program work? Injury Prevention. 2006 Oct;12(5):296–301.

Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, Wilson NL. Tai Chi and fall reductions in older adults: A randomized controlled trial. Journal of Gerontology: Medical Sciences. 2005 Feb;60A(2):187–94.

Logan PA, Coupland CA, Gladman JR, Sahota O, Stoner-Hobbs V, Robertson K, et al. Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. BMJ (Clinical research ed). 2010;340:c2102.

Lord SR, Castell S, Corcoran J, Dayhew J, Matters B, Shan A, Williams P. The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: A randomized, controlled trial. Journal of the American Geriatrics Society. 2003 Dec;51(12): 1685–92.

McKiernan FE. A simple gait-stabilizing device reduces outdoor falls and non-serious injurious falls in fall-prone older people during the winter. Journal of the American Geriatrics Society. 2005 Jun;53(6):943–7.

Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): Results from the randomized falls-HIT trial. Journal of the American Geriatrics Society. 2003 Mar;51(3):300–5.

156


Palvanen M, et al. Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 2014;45(1):265–71

*Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C. Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women. J Clinical Endocrinology and Metabolism. 2001

Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporosis International. 2009 Feb;20(2):315–22.

*Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: A meta-analysis of individual-level data. Journal of the American Geriatrics Society. 2002 May;50(5):905–11.

*Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697–701.

Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. Journal of the American Geriatrics Society. 2011;59(1):26–33.

Pit SW, Byles JE, Henry DA, Holt L, Hansen V, Bowman DA. A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial. Medical Journal of Australia. 2007 Jul 2; 187(1):23–30.

*Pit SW. Improving quality use of medicines for older people in general practice. University of Newcastle (Australia); 2004. PhD thesis.

*Pit, S., Byles, J. Older Australians’ medication use: self-report by phone showed good agreement and accuracy compared with home visit. Journal of clinical epidemiology. 2010 63:428–34.

*Pit, S.W., Byles, J.E., Cockburn, J. Prevalence of self-reported risk factors for medication misadventure among older people in general practice. Journal of Evaluation in Clinical Practice. 2008 14(2), 203–208.

*Pit, S.W., Byles, J.E. Accuracy of telephone self-report of drug use in older people and agreement with pharmaceutical claims data. Drugs and Aging. 2008 25(1), 71–80.

Pit, S.W., Byles, J.E., Henry, D.A., Holt, L., Hansen, V., Bowman, D. (2007) Quality Use of Medicines Program for general practitioners and older people: a cluster randomised controlled trial. Medical Journal of Australia. 2007 187(1), 23–30.

*Pit, S.W., Byles, J.E., Cockburn, J. Medication review: patient selection and general practitioner’s report of medication-related problems and actions taken. Journal of the American Geriatrics Society. 2007 55(6), 927–934.

157

APPENDICES

*Robertson MC, Gardner MM, Devlin N, McGee R, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres. British Medical Journal. 2001 Mar 24;322(7288):701–4.

Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker JO, Pietruszka FM, Robbins, AS. Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men. Journal of Gerontology: Medical Sciences. 2000 Jun;55A(6):M317–21.

Salminen MJ, Vahlberg TJ, Salonoja MT, Aarnio PTT, Kivelä SL. Effect of a risk-based multifactorial fall prevention program on the incidence of falls. Journal of the American Geriatrics Society. 2009 Apr;57(4):612–9.

*Salminen M, Vahlberg T, Sihvonen S, Piirtola M, Isoaho R, Aarnio P, Kivelä SL. Effects of risk-based multifactorial fall prevention on maximal isometric muscle strength in community-dwelling aged: A randomized controlled trial. Aging Clinical and Experimental Research. 2008 Oct;20(5):487–93.

*Salminen M, Vahlberg T, Sihvonen S, Sjösten N, Piirtola M, Isoaho R, Aarnio P, Kivelä SL. Effects of risk-based multifactorial fall prevention on postural balance in the community-dwelling aged: A randomized controlled trial. Archives of Gerontology and Geriatrics. 2009 Jan–Feb; 48(1):22–7.

*Sheik J, Yesavage J. Geriatric depression scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontology: A Guide to Assessment and Intervention. New York: The Haworth Press, Inc. 1986:165–73.

*Sjösten NM, Salonoja M, Piirtola M, Vahlberg T, Isoaho R, Hyttinen H, Aarnio P, Kivelä SL. A multifactorial fall prevention programme in home-dwelling elderly people: A randomized-controlled trial. Public Health. 2007 Apr;121(4):308–18.

*Sjösten NM, Salonoja M, Piirtola M, Vahlberg T, Isoaho R, Hyttinen H, Aarnio P, Kivelä SL. A multifactorial fall prevention programme in the community-dwelling aged: Predictors of adherence. European Journal of Public Health. 2007 Oct;17(5): 464–70.

*Skelton DA. Effects of physical activity on postural stability. Age and Ageing. 2001 Nov;30(Suppl 4):33–9.

*Skelton DA. The Postural Stability Instructor: Qualification in the United Kingdom for effective falls prevention exercise. Journal of Aging and Physical Activity. 2004 Jul;12(3);375–6.

*Skelton DA, Dinan SM. Exercise for falls management: Rationale for an exercise program aimed at reducing postural instability. Physiotherapy Theory and Practice. 1999 Jan;15(2):105–20. Available at http://www.laterlifetraining.co.uk/about/publications/

Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise—FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age and Ageing. 2005 Nov;34(6):636–9.

*Skelton DA, Stranzinger K, Dinan SM, Rutherford O. BMD improvements following FaME (falls management exercise) in frequently falling women age 65 and over: An RCT. Journal of Aging and Physical Activity. 2008 Jul;16(Suppl):S89–90.

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http://www.laterlifetraining.co.uk/about/publications/

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Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Archives of Physical Medical Rehabilitation. 2010;91(11):1705–11.

*Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. The development of a multi-modal fall prevention program for persons with osteoporosis M.L. Vincent, T.M. Moreau (Eds.), Accidental falls: causes, preventions and interventions, Nova Publisher Inc, New York (2008), pp. 185–201.

Spice CL, Morotti W, George S, Dent THS, Rose J, Harris S, Gordon CJ. The Winchester falls project: A randomised controlled trial of secondary prevention of falls in older people. Age and Aging. 2009 Jan;38(1):33–40.

Spink MJ, Menz HB, Fotoohabadi MR, Wee E, Landorf KB, Hill KD, et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial. BMJ (Clinical research ed). 2011;342:d3411.

*Tideiksaar R. Preventing falls: Home hazard checklists to help older patients protect themselves. Geriatrics. 1986 May;41(5):26–8.

*Tinetti ME, Baker DI, Garrett PA, Gottschalk M, Koch ML, Horwitz RI. Yale FICSIT: Risk factor abatement strategy for fall prevention. Journal of the American Geriatrics Society. 1993 Mar;41(3):315–20.

Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, Koch ML, Trainor K, Horwitz RI. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine. 1994 Sept 29;331(13):821–7.

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*Weerdesteyn V, Rijken H, Geurts AC, Smits-Engelsman BC, Mulder T, Duysens J. A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly. Gerontology. 2006;52(3):131–41.

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*Wolf SL, Coogler C, Xu T. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Archives of Physical Medicine and Rehabilitation. 1997 Aug;78(8):886–92.

*Yamada M, Aoyama T, Arai H, Nagai K, Tanaka B, Uemura K, Mori S, Ichihashi N. Complex obstacle negotiation exercise can prevent falls in community-dwelling elderly Japanese aged 75 years and older. Geriatric and Gerontology International. 2012 Jul;12(3):461–7.

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*Yamada M, Tanaka B, Nagai K, Aoyama T, Ichihashi N. Trail-walking exercise and fall risk factors in community-dwelling older adults: preliminary results of a randomized controlled trial. Journal of the American Geriatrics Society. 2010 Oct;58(10):1946–51.

*Supplemental Article

Appendix C: Original Intervention Materials

Appendix C: Original Intervention Materials Appendix C-1 Barnett Materials Exercises 161

Appendix C-2 Kovacs Materials 166

Appendix C-3 Voukelatos Materials 167

Appendix C-4 Wolf Materials 169

Appendix C-5 Haran Materials 173

Appendix C-6 Pit Materials 176

Appendix C-7 Spink Materials 179

Appendix C-8 Close Materials 194

Appendix C-9 Spice Materials 201

160


Appendix C-1 barnett Materials Exercises

1.Warm Up

Breathe in deeply through nose, lift arms above head and stretch. Lower arms and breathe out 6 times.

2. Shoulder rolls (flexibility)

Gently rotate shoulders up to ceiling, backwards, and down. Then reverse: up, forward and down. 6 times each way.

3. March on spot (mobility)

Hold onto chair with 2 hands. Walking on the spot. Try to lift knees a bit higher than usual. Step 10 times with each leg.

4. Ankle (strength)

Hold onto chair. Rise up onto toes of both feet, hold for 5 seconds, then lower. Keep heels on the floor and lift toes off the floor; hold for 5 seconds. Repeat both movements 6 times.

5. Knee bend (strength)

Hold onto chair. Stand with knees soft and back straight. Keeps knees pointing over toes. Bend your knees gently, and then raise your body by straightening your knees. Do this 6 times.

6. Sit to Stand (strength)

Sit in chair against wall. Stand up without using your hands 6 times. If this is too hard, use a pillow on the chair to start until you get stronger.

161

APPENDICES

7. Calf (stretch)

Hold onto chair; stretch one leg behind, toes facing forward, gently bend front knee until you feel a stretch in your calf. Hold stretch for 10 seconds. Do 6 stretches.

8. Calf (stretch)

Hold onto chair, stretch as in previous exercise. When you feel the stretch in your back calf, keep the heel of that foot on the ground, and slightly bend the back knee.

General Information on ExerciseAs we age our muscles tend to become less flexible and strong, and our joints become stiffer. This can affect our balance. Exercise is the best way to improve strength and mobility. Greater strength and mobility means you may be able to recover your balance if you lose it, therefore avoiding a fall.

Tips for Exercising • Wear comfortable clothes and shoes

• Drink some water before and after the exercise.

• Do exercises slowly and gently

• If you feel pain STOP that exercise and discuss with your exercise leader or project manager

• If you feel breathless or dizzy, STOP and rest.

Well done. You have now completed all the exercises. If you have any questions or concerns regarding the exercise program please don’t hesitate o contact your gentle exercise leader or project manager.

162


Stage 1 home program—Stay Safe Stay Active: Falls prevention in Primary Care 2001, SWSAHSStay Safe Stay Active Daily Exercise Program (Stage 1)

163

APPENDICES

Stay Safe Stay Active Daily Exercise Program (Stage 2)

164


Stay Safe Stay Active Daily Exercise Program (Stage 2)

1 Medications Discuss with GP or Pharmacist if you feel they may be causing drowsiness or dizziness.

2 The environment Loose rugs, slippery surfaces, unsecured cords, poor lighting especially at night, and spills of water or grease, all increase the risk of falling. Try and clear away clutter, especially where you need to walk, and secure rugs with grippers to the floor. Mop up any spills immediately.

3 Shoes Wear non-slip shoes that fit well, and have laces or Velcro fastening. Shoes with medium or low heels, which are rounded, are better than high thin heels. Slippers and thongs are not a good idea, as they do not offer enough support. Be careful of wet or slippery surfaces.

4 Hearing A loss of hearing can cause dizziness and balance problems, see your GP if this occurs. It could be something as simple as a lump of wax.

5 Vision Adequate lighting is very important, do not forget to turn the light on if you get up at night, or keep a nightlight on - keep your glasses by your bed! Bifocals can make going up and down stairs difficult as they alter the perception of where the stair edges are. When walking outside in the sun it is useful to wear a broad rimmed hat, it helps you pick up contrasts on the ground such as steps and edges. Remember to have annual eye tests, as this can detect any changes in your vision.

6 Good diet Eat a well balance diet, and don’t allow yourself to become too thin.

7 Colds/Sinus If you have a cold or sinus problems then take extra care as this can affect your balance.

8 Walking aid If you use a walking aid, make sure the rubber on the bottom is not worn, and keep it by your bed at night in case you need to get up.

If you do fall in the house do not panic. Stay still for a few minutes to get over the shock. If you are OK try to slide yourself over to a sturdy piece of furniture, sofa, bed or chair and position yourself along side of it. Get into a kneeling position and gradually push yourself up and sit down until you recover. If you are unable to move try to cover yourself with something to keep warm until help arrives.

165

APPENDICES

Appendix C-2 Kovacs Materials

Exercises Purpose Means of progression and adaptation

First part: Structured exercises with music chosen by participants

Lift arms over head

Lower arms to side and reach toward the floor

Strengthening of trunk muscles

Posture correction

Increase repetitions from 4–8

Standing

Steps in multiple directions BOS1 change Amount of support

Increase repetitions and speed of stepping

Reaching overhead and to side behind a chair

COG2 change in direction of reach Amount of support

Increasing distance of reaching

Partial squats Strengthen lower limb muscles Increase repetitions from 4–8

Turning while standing Functional activity Increase repetition and turning speed

Tandem standing Decrease of BOS1 while standing Increase duration

Sit to stand and stand to sit Functional activity Increase repetitions

Stepping in place with high knees BOS1 change in dynamic context Increase height of stepping

Second part: physical activity chosen by participants: relay race OR ballgames

Heel walking

Toe walking

Walking on line

BOS1 change in functional context Increase distance

Walking on exercise mat Walking on uneven terrain Increase distance

Decrease mat stiffness

Slalom walking between cones BOS1 change in functional context Increase number of cones Decrease distance between cones

Walking backward Increase distance

Picking up and transferring objects placed on the floor

Ankle and hip balance strategy training involving practicing dual task

Change size and weight of objects

Stepping in and out of hoops placed on the floor

BOS1 change in functional context Increase number of hoops and decrease distance between hoops

Ballgames

Catching and throwing balls in different directions

Vestibular stimulation

Multiple task activity

Decreasing size and increasing weight of the ball. Begin with a balloon then progress to heavier and smaller balls. The speed of the game will increase

Adapted basketball Vestibular stimulation

Multiple task activity

Increase length of play and size of course

1BOS: Base of Support 2COG: Center of Gravity

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Appendix C-3 Voukelatos Materials

Tai Chi Principles for Falls Prevention in Older PeopleThe following notes are suggestions for incorporation into a Tai Chi program specifically targeting falls prevention in older people.

BALANCE—the key element to preventing a fall Balance has been shown to decrease with age; however, some aspects of balance can be enhanced through training.

Key elements to incorporate into a Tai Chi program Relaxation relaxes muscles lowers center of gravity

Lowered center of gravity increases load on lower limbs over time increases sensation and awareness of lower limb movement.

Transfer of weight Shifting body weight from leg to leg through incremental movements. Start with a small range of movement and gradually build up to a wide, square base stance.

Muscle strength Muscle bulk and therefore strength decrease with age. A bent knee stance and movement works to strengthen lower limb muscle (particularly the quadriceps muscles) (however, always work to an individual’s limitations. If a bent knee stance is too difficult, then do the movement without bent knees).

Instability This involves issues such as increased body sway, low mobility, and postural instability. Increasing age is also associated with reduced sensation in lower limbs and is consequently associated with a loss of righting reflexes and an increase in body sway, which can lead to falls.

Gait: decreased stepping height and decreased stride length.

Women tend to have a narrow walking and standing base, closer foot placement, erect posture difficult to step down from stools/benches.

Men tend to have a small-stepped gait, wider walking and standing base, and stooped posture.

Tai Chi addresses gait problems by teaching “correct” movement of lower limbs. This is done by lifting lower limbs from the knee rather than the foot; lifting lower limbs without misaligning the pelvis; and teaching to place heel down first when moving forward (toes first when moving back). Also, teaching movement with appropriate weight transfer, posture, and slightly bent knees improves stride length.

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APPENDICES

Posture: Tai Chi also teaches participants to maintain a relaxed posture with an elongated spine.

Coordination/Mobility: Tai Chi consists of a moving from one stance to another in a slow, coordinated, and smooth way. This trains students in improved mobility and increased body awareness.

Guidelines for Instructors Working with Older People

• Important to maintain an upright (straight) posture at all times.

• Incremental movement is needed in teaching older people.

• Instructors need to be well aware of an individual’s comfort level and not go beyond that.

• In bent knee stance, must remember to introduce bent knee gradually throughout the 16-week period while staying within comfort levels of individuals.

• Remember to keep the center line of gravity as perpendicular as possible and center within the base stance.

• Tai Chi leaders also have to be mindful of any medical or physical conditions students might have that would interfere with standard Tai Chi movements. For example, if a practitioner has had a hip replacement then the range of movements involving hips may be limited.

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Appendix C-4 Wolf MaterialsDirections and Therapeutic Elements for Learning 10 Forms of Tai Chi

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APPENDICES

FORM 1. Directions1. Stand upright with feet shoulder-width

apart, toes pointing forward, arms hanging naturally at sides. Look straight ahead (1A).

2. Raise arms slowly forward to shoulder level, palms down.

The hands do not go above the shoulders and the elbows are held in (1B & 1C).

3. Bend knees as you press palms down gently, with elbows dropping towards knees. Look straight ahead (1D).

FORM 1. Therapeutic elements 3, 4

This “warm-up” form begins with non-stressful bilateral stance where all thoughts other than those about movement clear the head. Attention is directed to relaxing all muscles except those of the legs—the feet are to “stick to the ground.” As movement begins, concentration is directed to move all four extremities at the same constant speed that begins and ends concomitantly in the arms and legs.

FORM 2. Directions

The body is turned slightly to the left, with left foot at 9 o’clock for a left bow stance. The left forearm and back of hand are at shoulder level, while right hand is at the side of fight hip, palm down. Look at left forearm (2A). Turn torso slight to left (9 o’clock) while extending left hand forward, palm down. Turn torso slightly right while pulling both hands down in a curve past abdomen, until right hand is extended sideways at shoulder level, palm up, and left forearm is across chest, palm turned inward. Shift weight onto right leg. Look at right hand (2B). past face, palm turned slowly outward, while left hand moves in a curve past abdomen

up to shoulder level with palm turned slowly obliquely inward (4B & 4C).

FORM 2. Therapeutic elements 1–7

The trunk and head rotate while both feet remain on floor. The arms move in asymmetrical positions so that the center of mass is extended further from left to right due to arm positions. The trunk and head are kept erect so that rotation is around a central axis. The body weight is predominantly on a flexed leg for greater balance and strength mechanism.

FORM 3. Directions

Look straight ahead; face 9 o’clock with weight on left leg in a bow stance and hands forward at shoulder height in a pushing position (3A). Turn both palms downward as right hand passes over left wrist, moves forward, then to the right until it is on the same level with left hand. Separate hand shoulder-width apart and draw them back to the front of abdomen, palms facing obliquely downward. At the same time, sit back and shift weight onto right leg, slightly bent, raising toes of left foot. Look straight ahead (3B & 3C).

FORM 3. Therapeutic elements 1–4 & 7

The body center of mass moves diagonally posteriorly than other forms with a decreased base of support from only heel contact of the left leg, demanding greater balance and strength than the previous form. The trunk rotation is decreased and the arm movement is symmetrical

FORM 4. Directions

Turn torso to the left (10–11 o’clock), shifting weight to left leg. Move left hand in a curve past face with palm turned slowly leftward, while right hand moves up to the front of left

170


shoulder with palm turned obliquely inward. As right hand moves upward, fight foot and left foot are parallel and 10 to 20cm apart. Look at right hand (4A). Turn torso gradually to the right (1 to 2 o’clock), shifting weight onto right leg.

At the same time, move right hand continuously to right

While the legs are symmetrical, weight is shifted laterally. The arms are asymmetrical, the trunk and had rotate with arm movement. Both knees are flexed and weight shifts to the leg on the side to which the arms are moving.

FORM 5. Directions

Turn torso slightly to the fight, moving right hand down in a curve past abdomen and then upward to shoulder level, palm up and arm slightly bent. Turn left palm up and place toes of left foot on floor. Eyes first look to the right as body turns in that direction, and then to look at left hand (5A & 5B).


Again a smaller base of support with the majority of weight on one extremity. The arm on the weight bearing side is curved back into shoulder extension. Done on the right leg and then reversed and done on the left leg. Again trunk rotates at the end of the movement.

FORM 6.Directions

Hold torso erect and keep chest relaxed. Move arms in a curve without stretching them when you separate hands. Use waist as the axis in body turns. The movements in taking a bow stance and separating hands must be smooth and synchronized in tempo. Place front foot slowly in position,

heel coming down first. The knee of front leg should not go beyond toes while rear leg should be straightened, forming a 45 with ground. There should be a transverse distance of 10 to 30cm between heals. Face 9 o’clock in final position.


Hand assumes a position of holding a ball initially. Movements in the form are diagonals and rotations of the trunk and head. Movements slide back and forth in and out of 6A and 6B, and then position is reversed for right and left.

FORM 7. Directions

Turn torso to the right (11 o’clock) as right hand circles up to ear level with arm slightly bent and palm facing obliquely upward, while left hand moves to the front of the right part of chest, palm facing obliquely downward. Look at right hand (7A). Turn torso to the left (9 o’clock) as left foot takes a step in that direction for a left bow stance. At the same time, right hand draws leftward past right ear and, following body turn, pushes forward at nose level with palm facing forward, while left hand circles around left knee to stop beside left hip, palm down. Look at fingers of right hand (7B & 7C).


This form begins in the position of 7 A, but with both feet flat on the floor. They remain on the floor throughout the exercise. Move in and out of the position 7 A, B, C, A, B, C, then reverse right-left positions.

FORM 8. Directions

Continue to move hands in a downward-inward-upward curve until wrists come in front of chest, with right hand in front and

171

APPENDICES

both palms turned inward. At the same time, draw right foot to the side of left foot, toes on floor. Look forward to the right (SA). Separate hands, turning torso slightly to S o’clock and extending both arms sideways at should level with elbows slightly bent and palms turned outward. At the same time, raise right knee and thrust foot gradually towards 10 o’clock. Look at right hand (8B & 8C).


With the elderly, the kick is only a small part of their available range. The form is utilized for kicking with both dorsiflexion and plantar flexion of the foot. Forms 8 and 9 are the most stressful for maintaining balance due to the small base of support and the extreme movement of the kicking leg. However, forms are done continuously with slow movements and a strong degree of concentration. The range for the kick is not extreme in the elderly.

FORM 9. Directions

Shift weight onto right leg and draw left foot to the side of right foot, toes on floor. At the same time, move both hands in a downward-inward-upward curve until wrists cross in front of chest, with left hand in front and both palms facing inward. Look forward to the left (9A & 9B). Separate hands, extending both arms sideways at shoulder level, elbows slightly bent and palms facing outward. Meanwhile, raise left knee and thrust foot gradually towards 4 o’clock. Look at left hand (9C & 9D).


The same as Form S but right and left are reversed.

FORM 10. Directions

Turn palms forward and downward while lowering both hands gradually to the side of hips. Look straight ahead (10A, 10B & 10C).

FORM 10. Therapeutic elements

This is a warm-down form like Form 1 and constitutes both a physical and mental ending of the exercise.

Materials reprinted with permission from Wolf SL, Coogler C, Xu T. Exploring the basis for Tai Chi Chuan as a therapeutic exercise approach. Archives of Physical Medicine and Rehabilitation. 1997;78:886–892.

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Appendix C-5 Haran Materials

The optometrist re-administering the tests of depth perception (figure A) and distance edge contrast sensitivity (Figure B) with participants viewing the visual stimuli through upper and lower portion of their multifocal lenses and distance lenses. A chin rest was used to prevent neck flexion, thereby forcing the person to look through the lower portion of the multifocal lens during testing.

FIGURE A—DEPTH PERCEPTION—HOWARD-DOHLMAN device at 3 meters

Figure B—VISUAL CONTRAST—135 cm Melbourne Edge Test

173

APPENDICES

FIGURE C—Streetscape

Image A Image B

Figure C. Simulated view of street scenes as viewed through single lens distance glasses and bifocal glasses. The footpath misalignment (the commonest reported environmental factor involved in outdoor falls) is clearly seen in Image A but blurred in Image B.

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FIGURE D—View of shaded stairs

a) Seen through distance glasses b) Seen through bifocal glasses

SIDE 1 of card

When to use your new DISTANCE GLASSES:

• Walking on stairs indoors and outside

• Getting into or out of a vehicle

• Walking in a street or shopping centre

• Walking in buildings other than your home

• Walking in gardens or on uneven ground(Please turn over)

SIDE 2 of card

Use your BI, TRI & MULTIFOCALS when:

• Walking in your own home on level ground

• Sitting at a desk, table or on a lounge

• Driving

• Working at a bench

• Selecting items from a shelf

175

APPENDICES

Appendix C-6 Pit Materials

176


177

APPENDICES

178


Appendix C-7 Spink Materials

Appendix 1: FOOTWEAR ASSESSMENT TOOL 1. FIT

Foot length Thumb width

Fit of shoe (length) – rule of thumb (wearer’s thumb)

Palpation: good too short (< ½ thumb) too long (> 1 ½) Straw = good too short (< ½ thumb) too long (> 1 ½)

Fit of shoe (width) – grasp test good too narrow too wide Fit of shoe (depth) good too shallow

2. GENERAL

Age of shoe 0 – 6 months 6 – 12 months > 12 months

Footwear style

walking shoe athletic shoe oxford shoe moccasinboot ugg-boot high heel Thong/flip-flop

slipper backless slipper court shoe mulesandal surgical/bespoke other (specify)

Materials (upper) leather synthetic mesh other Materials (outsole rubber plastic leather other

Weight Length Weight/length

3. GENERAL STRUCTURE

Heel height =

0 – 2.5 cm 2.6 – 5.0 cm > 5.0 cm

Forefoot height (measured at point of the 1st and MTPJs) =

0 – 0.9 cm 1.0 – 2.0 cm > 2.0 cm

Longitudinal profile (heel – forefoot difference) =

flat (0 – 0.9 cm) small heel rise (1 – 3 cm) large heel rise (> 3 cm)

Last (centre goniometer at 50% shoe length) =

straight (< 5°) semi-curved (5 – 15°) curved (> 15°)

Fixation of upper to sole

board combination slip-lasted

Forefoot sole flexion point

at level of MTPJs proximal to 1st MTPJ distal to 1st MTPJ

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APPENDICES

4. MOTION CONTROL PROPERTIES

Density single dual

none laces straps/buckles Velcro zipsFixation Number of eyelets

Heel counter stiffness (20mm above bottom or upper)

no heel counter minimal (> 45°) moderate (< 45°) rigid (0-10°)

Midfoot sole sagittal stability

minimal (> 45°) moderate (< 45°) rigid (0-10°)

Midfoot sole frontal stability (torsional)

minimal (> 45°) moderate (< 45°) rigid (0-10°)

5. CUSHIONING

Presence none heel heel/forefoot

Lateral Midsole hardness soft firm hard

Durometer readings 1st 2nd 3rd mean

Medial Midsole hardness soft firm hard


Heel sole hardness (centre of inside heel shoe interface) soft firm hard


6. WEAR PATTERNS

Upper medial tilt (> 10°) neutral lateral tilt (> 10°)

Midsole medial compression signs neutral lateral compression signs

A textured smooth (i.e. no pattern) Tread pattern B not worn partly worn fully worn

Outsole wear pattern none normal lateral medial

R L

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FALLS RCT La Trobe University, Musculoskeletal Research Centre, Bundoora

3. Safe shoe information

LACK OF LACES MEANSYOUR FOOT CAN SLIDE

OUT OF THE SHOE

SLIPPERY OR WORN SOLESARE A BALANCE HAZARD,

PARTICULARLY IN WET WEATHER

HIGH HEELS SHOULDBE AVOIDED AS THEY IMPAIRSTABILITY WHEN WALKING

NARROW HEELS MAKE YOURFOOT UNSTABLE AND CAN

CAUSE ANKLE SPRAINS

SOFT OR STRETCHED UPPERSMAKE YOUR FOOT SLIDE AROUND

IN THE SHOE

A FIRM HEEL COLLARTO PROVIDE STABILITY

A BEVELLED HEELTO PREVENT SLIPPING

A TEXTURED SOLETO PREVENT SLIPPING

A THIN, FIRM MIDSOLESO YOU CAN 'FEEL' THEGROUND UNDERNEATH

A BROAD, FLARED HEELTO MAXIMISE CONTACT

WITH THE GROUND

LACES ENSURE THE SHOE'HOLDS' ONTO YOUR FOOT

WHEN WALKING

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APPENDICES


5. Exercise Program

Increased strength and range of motion of the joints has been shown to prevent falls.

You have been given the following exercise program to perform to help improve your

strength and movement in the feet and ankles. Please perform this three times a week on

days that are convenient to you.

The following pages contain instructions and pictures describing the exercises that were

demonstrated to you at the appointment. Please use the instructions and pictures to help

you as you perform your exercise program. If you have a DVD player at home, you would

have been also given an accompanying instructional DVD for the program.

You may experience some muscles soreness from doing your exercises. This is normal

with any strengthening program. If the muscle soreness makes it uncomfortable to

continue with the exercises, stop them for a couple of days until you feel better, then

resume again.

If the soreness does not improve after 48 hours, or if the soreness interferes with your

ability to sleep, stand or walk, stop all exercises and contact Martin Spink on 9479 5258.

Remember to tick the days on the exercise calendar that you performed the exercise

program.

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FALLS TRIAL HOME EXERCISE PROGRAM

WARM UP EXERCISE

1. Ankle circling

INSTRUCTIONS

Setup

1. Sit comfortably in a chair with both feet on the ground.

Clockwise circling exercise

1. Lift one foot off the ground and hold it up in the air.

2. Using slow and gentle movements, rotate ankle and circle foot in a clockwise direction, making as large a circle as possible.

3. Repeat 10 circles in clockwise direction, then place foot down to rest.

4. Lift the other foot off and repeat 10 clockwise circles using this foot.

Anti-clockwise circling exercise

1. Lift the first foot off the ground again and hold it up in the air.

2. This time, rotate the ankle and circle the foot in an anti-clockwise direction again making as large a circle as possible.

3. Repeat 10 circles in an anti-clockwise direction and then place the foot down to rest.

4. Lift the other foot off and repeat 10 anti-clockwise circles using this foot.

Dosage

Do only 1 set of 10 circles in each direction on each foot.

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APPENDICES


THERABAND EXERCISES

Attaching your theraband

Theraband

You have been provided with a piece of theraband that has been double-looped and knotted at its ends.

Attach the theraband loop around the leg of a sturdy table as shown:

1. Hold the double-looped theraband horizontal to the table leg with the knotted end pointing away from the table.

2. Loop the knotted end over the smooth end.

3. Pull the smooth end through and tighten the theraband around the table leg to ensure that it is secure.

Resistance

Start with ______________ theraband.

Once you can complete all 3 sets of 10 repetitions of the theraband exercises without any difficulty, progress onto ____________ theraband

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2. Ankle Inversion (turn-in) Exercise

INSTRUCTIONS

Setup

1. Place chair side-on to the table just behind where the theraband is attached and sit in it with your feet flat on the ground.

Inversion (turn-in) Exercise

1. Loop the free end of the theraband around your foot that is closest to the table, at the level of the base of the toes.

2. Pull your foot away from the table until the band is taut.

3. Place your hands on your exercising knee to prevent the knee from turning during the exercise.

4. Use your foot to pull on the theraband by slowly turning your foot away from the table leg and finishing with the inside sole of your foot off the ground facing away from the table leg.

5. Slowly return the foot back to flat on the ground.

6. Repeat exercise for 10 times.

185

APPENDICES


3. Ankle Eversion (turn-out) Exercise

INSTRUCTIONS

Eversion (turn-out) Exercise

1. When you have finished with the inversion exercise, remove the theraband from around the inside of your foot and loop it around the outside of your other foot in the same manner, at the level of the base of the toes.

2. Pull your foot away from the table until the band is taut.

3. Place your hands on your exercising knee to prevent the knee from turning during the exercise.

4. Use your foot to pull on the theraband by slowly turning your foot away from the table leg and finishing with the outside sole of your foot off the ground facing away from the table leg.

5. Slowly return the foot back to flat on the ground.

6. Repeat exercise for 10 times.

Dosage

Do 3 sets of 10 repetitions. Have a 30 second rest in between each set.

Turn the chair around and repeat the movements with the opposite feet. As before start with the inside foot for inversion, then change the theraband to the outside foot for eversion.

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4. Ankle Dorsiflexion (toe-up) Exercise

INSTRUCTIONS

Setup

1. Sit in a chair with both feet flat on the ground.

Exercise

1. Lift your toes on both feet off the ground as high as you can and hold for 10 seconds.

2. Ensure that your heels remain in contact with the ground at all times.

Dosage

Start with 1 set of 3 repetitions, holding for 10 seconds each time.

If you can do 3 repetitions without difficulty or muscle soreness the next day, increase by 1 rep to 4 repetitions of 10 seconds.

Keep increasing the number of repetitions until you reach 10 repetitions. It does not matter if you do not reach 10 repetitions.

You only need to do 1 set of repetitions for this exercise.

187

APPENDICES


5. Arch Exercise

INSTRUCTIONS

Setup

1. Sit in the chair with your feet on the ground and the ArchExerciser placed close to the exercising foot.

2. Position the exercising foot on the ArchExerciser as shown, with your heel on the grey-pad and your toes over the slider.

Exercise

1. Grip the slider with your toes and pull it back towards the heel by arching the middle of your foot.

2. Do not allow the heel to slide backwards or lift off the grey-pad.

3. Pull the slider back as far as possible, then slowly release it by relaxing your foot.

4. Repeat 10 times.

Dosage

Do 3 sets of 10 repetitions on each foot.

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6. Toe Strengthening Exercise

INSTRUCTIONS

Picking up marbles with toes

Setup

1. Sit comfortably in a chair.

2. Place 20 marbles on the floor and an empty container by the side of the marbles.

Exercise

1. Use your toes to pick up a marble off the floor.

2. Release it into the container.

3. Keep picking up the marbles with your toes until all 20 marbles have been picked up and released into the container.

4. Tip the marbles out onto the floor again, and repeat the exercise with your other foot.

Dosage

Repeat the exercise twice on each foot, each time picking up 20 marbles.

If you have difficulty with picking up all 20 marbles with your toes, just pick as many as you are able to.

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APPENDICES


7. Big Toe Stretch

INSTRUCTIONS

Big toe pull

Setup

1. Sit comfortably in a chair.

2. Loop the rubber band provided around both your big toes.

Exercise

1. Slide one foot away from the other until you feel a comfortable stretch in your big toes from the rubber band.

2. Keep both feet on the ground and hold the stretch in the big toes for 20 seconds.

3. Relax and return the foot back to starting position.

4. Repeat 3 times.

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8. Double Heel Raise Exercise

INSTRUCTIONS

Rising up on toes

Setup

1. Stand in front of a wall with hands on the wall for balance with your feet flat on the ground at a comfortable distance apart.

Exercise

1. Slowly rise up onto your toes on both feet.

2. Rise up as high as you can, then slowly lower yourself back down onto the ground.

3. Repeat the exercise for 10 times.

Dosage

Do 3 sets of 10 repetitions. Have a 30 second rest in between each set.

Progression

Start with 10 repetitions.

Once you can complete all 3 sets of 10 repetitions without any difficulty or soreness next day, increase the number of repetitions by 2 to 12, and do 3 sets of 12 repetitions.

Keep increasing the number of repetitions by 2 up to 50 as you are able to. It does not matter if you cannot go up to 50 repetitions.

191

APPENDICES


9. Calf Stretch in Standing

INSTRUCTIONS

Setup

1. Stand in front of a wall with your hands on the wall for balance, feet flat on the ground at a comfortable distance apart.

2. Place one foot backwards about a step length. Ensure the back heel is flat on the ground at all times. Keep your hips, knees and toes pointing forwards and square to the wall at all times.

Stretch

1. Keeping the back leg straight, slowly bend the front knee and bring yourself toward the wall.

2. Lean towards the wall until you feel a stretch in the calf muscle at the back of your leg.

3. If you have gone as far as you can and cannot feel a stretch, move your foot a little further behind and try again.

4. Once you feel a medium-strong stretch in the back leg, stop and hold the stretch for 20 seconds.

5. After 20 seconds, relax and have a little rest. Then repeat the stretch again.

6. Repeat the stretch 3 times on 1 leg. Then change foot by placing the other leg behind and repeat 3 stretches on times on the other leg.

DosageRepeat 3 times on each leg or as able. Hold the stretch for 20 seconds each time.

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SUMMARY OF EXERCISES AND DOSAGES

Name Dosage Increments

1. Ankle Circling Exercise 1 set x 10 circles in each direction on each foot

No increment

2. Ankle Inversion(turn-in) Exercise

3 sets x 10 repetitionson each foot, 30 seconds rest between sets

Increase resistance strength of Theraband™

3. Ankle Eversion(turn-out) Exercise

3 sets x 10 repetitionson each foot, 30 seconds rest between sets

Increase resistance strength of Theraband™

4. Ankle Dorsiflexion(toe-up) Exercise

1 set of repetitions,holding 10 seconds each time

Start with 3 repetitions, increase repetitions by 1 as able until you reach 10 repetitions

5. Arch Exercise 3 sets x 10 repetitionson each foot,30 seconds rest between sets

Increase amount of slider bar retraction as able

6. Toe Strengthening Exercise(Picking up marbles with toes)

2 sets x 20 marbleson each foot, 30 seconds rest between sets

If you have difficult with picking up marbles, start with picking as many as you can and increase as able up to 20.

7. Big Toe Stretch(Big toe pull)

1 set x 3 repetitions holding 20 seconds each time

Increase distance of toe stretch as able

8. Double Heel Raise Exercise(Rising up on toes)

3 sets x 10 repetitions,30 second rest between sets

Increase repetitions in each set by 2, up to 50 repetitions as able

9. Calf Stretch in Standing 1 set x 3 repetitionson each leg,holding 20 seconds each time

Increase distance of behind foot as able

193

APPENDICES

Appendix C-8 Close Materials

90

194


91

195

APPENDICES

92

196


Summary

Likely Cause of Fall

Risk Factors for Falls

Planned investigations and/or modifications

Follow up Arrangements

Referrals

FBC LFT’s

U&E TFT’s

ECG Vit D

Urinalysis

Signature: Print Date:

JCT Close; Mar 99

D-3, Close Materials, 4 of 10

93

197

APPENDICES

PROFET – Environmental Assessment

Name: Number:

At time of fall

In the home

In the environment

Slip Hazards 1 Liquid/solid spills 2 Wet floors 3 Incorrect footwear 4 Loose mats on polished

floors5 Rain, sleet, snow, ice 6 Change from wet to dry

surface7 Unsuitable floor surface 8 Dusty floors 9 Sloping surfaces

Trip Hazards 10 Loose floorboards / tiles 11 Loose and worn mats /

carpets12 Uneven outdoor surfaces 13 Holes / cracks 14 Change in surface level –

ramps, steps, stairs 15 Cables across walking areas 16 Obstructions17 Bumps, ridges and

protruding nails etc 18 Low wall and floor fixtures,

door catches, door stops etc. Risk Factors 19 Organisation of walkways

20 Badly placed mirrors / reflections from glazing

21 Poor or unsuitable lighting 22 Wrong cleaning regime /

materials 23 Moving goods, carrying,

pushing or pulling a load 24 Rushing around 25 Distractions 26 Fatigue27 Effects of alcohol 28 Effects of other drugs 29 Other factor (describe)

Close-PROFET.

D-3, Close Materials, 5 of 10

94

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95

199

APPENDICES

96

200


Appendix C-9 Spice Materials

Winchester Falls Project—Structured Secondary Assessment Domains

Question 1—Basic information

Name: _________________________________

Address: _______________________________

GP: ____________________________________

DOB: __________________________________

Date of assessment: ______________________

Date of referral: __________________________

Question 2—Home

House/flat/bungalow/sheltered/RH/NH/independent

Question 3—Walks

Independent/stick/frame

Question 4—Carers

Independent/family/carers

Question 5—Bowels

Independent/continent or continent with help or incontinent occasionally or incontinent or stoma

Continence aids _________________________

Question 6—Bladder

Independent/continent or continent with help or incontinent occasionally or incontinent or catheter

Continence aids _________________________

Question 7—Falls history

How many times has/she or he fallen before this last fall: once/2–5/>5

Has the patient sustained an injury during any fall: yes/no

If yes, which sort: ________________________

Head injury: yes/no

Fracture/dislocation: yes/no (please specify) _______________________________________

_______________________________________

Laceration requiring medical attention: yes/no

Bruising: yes/no

Others: yes/no (please specify) _______________________________________

_______________________________________

Definite slip/trip: yes/no

Loss of consciousness: yes/no

Associated dizziness/palpitations: yes/no

Vertigo: yes/no

Presyncope: yes/no

Question 8—Drug history

List all medications (including over the counter and prescribed)

_______________________________________

_______________________________________

_______________________________________

_______________________________________

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APPENDICES

Question 9—Drugs

Is the patient taking any of the following drugs:

Diuretics _______________________________

Hypnotic/sedative _______________________

Antidepressant __________________________

Digoxin ________________________________

Cardiovascular __________________________

Anti-parkinsonian ________________________

Question 10—Alcohol consumption

CAGE score _____________________________

Total number of units/week ________________

Question 11—Smoking

Do you smoke: yes/no

If yes: cigarettes/pipe/cigars

Question 12—Past medical history

Heart disease ___________________________

Stroke/TIA ______________________________

Respiratory disease ______________________

Hypertension ___________________________

Diabetes _______________________________

Epilepsy ________________________________

Parkinson’s disease _______________________

Visual problems: wears glasses and last eye check within 2 years ___________________________

Joint disease ____________________________

Other neurological disease ________________

_______________________________________

Other diseases: __________________________

_______________________________________

_______________________________________

Question 13—Examination BP

Weight _________________________________

BP lying ________________________________

BP standing immediately __________________

BP at 1 minute __________________________

BP at 3 minutes __________________________

Question 14—MTS _____________________

Question 15—Vision ___________________

Visual acuity with glasses/pin hole: __________

Right __________________________________

Left ___________________________________

Question 16—Pulse ____________________

Question 17—Rhythm __________________

Question 18—Heart sounds ____________

Question 19—Cranial nerves

Range of eye movements _________________

Visual fields _____________________________

Fundi __________________________________

Pupils __________________________________

Other findings __________________________

_______________________________________

_______________________________________

Question 20—Peripheral neurology

Tone (right and left) ______________________

Power (right and left) _____________________

Reflexes (right and left) ___________________

Sensation (right and left) __________________

Cerebellar (right and left) __________________

202


Question 21—Chest examination

_______________________________________

_______________________________________

Question 22—Abdominal examination

_______________________________________

_______________________________________

Question 23—Other findings

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Question 24—Mobility/gait

Aid used and pattern _____________________

Pattern ________________________________

Heel strike ______________________________

Stance _________________________________

Stride __________________________________

Other __________________________________

Stairs __________________________________

Question 25—Joint range and muscle strength

Joint range _____________________________

Upper limbs ____________________________

Cervical spine ___________________________

Lower limbs ____________________________

Lumbar spine ___________________________

Muscle strength _________________________

Upper limbs ____________________________

Cervical spine ___________________________

Lower limbs ____________________________

Lumbar spine ___________________________

Question 26—Getting up from the floor

Pattern: independently/assistance x 1/assistance x 2/unable

Comment: ______________________________

_______________________________________

_______________________________________

Question 27—Transfers

Bed ___________________________________

Chair __________________________________

Toilet __________________________________

Bath (reported) __________________________

203

APPENDICES

Question 28—Equipment

Equipment already in situ _________________

Question 29—Domestic activities of daily living (reported)

Make a hot drink _________________________

Prepare a meal __________________________

Washing up _____________________________

Use cooker _____________________________

Cleaning _______________________________

Laundry ________________________________

Shopping ______________________________

Carrying and lifting ______________________

Question 30—Personal activities of daily living (reported)

Wash and dry self ________________________

Dress and undress _______________________

Clothes fastenings _______________________

Stockings and socks ______________________

Shoes and slippers _______________________

Personal care ___________________________

Question 31—Timed unsupported steady stand

Time in seconds for unsupported/single hand/ double hand stand ______________________

Distance between heels ___________________

Question 32–180 degree turn ______________

Number of steps _________________________

Time in seconds _________________________

Question 33—Functional reach _____________

Done standing in dominant arm (measured in inches) _____________________

Question 34—6 meter timed walk

Time in seconds _________________________

Number of steps _________________________

Question 35—Single leg stand

Right leg _______________________________

Left leg ________________________________

Question 36—Clothing and footwear hazards

Clothing _______________________________

Footwear _______________________________

Chiropodist: yes/no

Question 37—Pain

Pain: no pain/ongoing chronic pain/acute and intermittent pain/ongoing and acute

Description _____________________________

_______________________________________

_______________________________________

_______________________________________

Question 38—Problem list

_______________________________________

_______________________________________

_______________________________________

Question 39—Action list

_______________________________________

_______________________________________

_______________________________________

204


Question 40—Likely cause of fall

Musculoskeletal _________________________

Cardiovascular __________________________

Environmental __________________________

Medication _____________________________

Vision _________________________________

Alcohol ________________________________

Other __________________________________

Combination ____________________________

Comments _____________________________

_______________________________________

_______________________________________

Question 41—Risk factor for falls

Medication _____________________________

Vision _________________________________

Alcohol ________________________________

Postural hypotension _____________________

Footwear _______________________________

Mobility ________________________________

Medical—neurological ____________________

Medical—musculoskeletal _________________

Medical—cardiovascular __________________

Environmental __________________________

Other __________________________________

Combination ____________________________

Comment ______________________________

_______________________________________

_______________________________________

Question 42—Planned investigations and/or interventions _______________________

_______________________________________

Question 43—Follow-up arrangements/referrals ______________________________

_______________________________________

Question 44—Timings

Physician: ______________________________

Physiotherapist: _________________________

Nurse: _________________________________

Occupational therapist: ___________________

Other (please specify): ____________________

_______________________________________

_______________________________________

205

APPENDICES

CS254785-A

cdc compendium of effective fall interventions: what works for

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